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Please.print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050.0039 <br /> UMF®RM H DpUS; 1.Ganerator'ID Number J 2.Page i of 3,Emer�e_n_cy Response Phone 4,Manliest Trackin Num er <br /> WASTE MANIFESTA55`.V 7 f 4i .Li 91T 2009 92 <br /> 403 EL <br /> E- <br /> 5.Generators Name and-Mallin Add enerator's Site Address(ii different than mailing address) <br /> t�J rrstt- �G SgECYGLI iG Atn a Karat Mootincal <br /> J20()ta.EI Dorado St, ) <br /> Stooktofl,GA 952.16 <br /> .Generator's Phone: ' <br /> 6,Transporter 1 mpany Name U.S.EPA ID Number . <br /> Urr*n Paui32r,Wes�-'C 1 <br /> 7.Transporter 2 Company Name, U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> ��`���n�tlroftyrt�n # t�Ttr���i3i 2a;3� <br /> t i 19'West Hiowiw 123 <br /> East ,Lr $4620 USA <br /> Facllity�s Phone: 1 <br /> 9y. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 18.Containers 11,Total 12.Unit 13,Waste Codes <br /> HM and Packing Group(it any)) No. Type Quantity Wt Vol. <br /> 1 rel W--CRA€AZARD:S''VV TE.'.'50UD folia-00T replaced' all KG <br /> W 2 <br /> 3, <br /> 4, <br /> 14:Special Handling Instructionsand Addidprtpl Information <br /> a . . <br /> t31011V YCLNG PROJKT -RAILGAR NO. '$ <br /> t <br /> 16, GENERATOR'5IOFFEROR'SLERTIFICA7ION: I hereby declare that the contents of this consignment are futiy and accurately described above by the prop&shipping name,and are dessiW`packaged, <br /> marked and labeledlplacardsd,and are in all respects to proper condition for transport according to apydicable International and national governmental regulations.If export shipment and ti am the Primary <br /> Exporter,I certify,that Ore contents of this consignment conform to the terms of the attached EPAAdmowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 282.27(a)(it 1 am a large quantity generatw)or(b)(d I am a small quantity ga rator)is true. <br /> eratot eror's Prin(ed)TName Month Day ear <br /> _t 16.International Shipments <br /> P— ❑Import to U.S. t_._I Export from U.S. Port cf anbylerjC <br /> Z Transporter signature for exports only): Data leaving U.S.: <br /> w 17.Transporter Ac uiciwledgment of Receipt of Materials f <br /> Transporter 1 Pdntadfryped Na signature month Day ear <br /> tPIC al Ii <br /> Q7ranspontr 2 Printatl—5t Name Signature Month Day Year <br /> 18.Discrepancy tt—� <br /> i8a.Discrepancy Indicagon Space 0 Quantity ❑Type t I Residue ❑Partial Rejackon El Full Rejection <br /> Manifest Referents Number. <br /> 18b.Attemate Facility(or Generator) U.S.EPA ID Number <br /> LL; Fadlitvs Phone: <br /> w..18c.Signature ofAlemateFacility.(orGenerator} Nortth Day Year <br /> Q <br /> 19.Hazardous Waste Report Management arlethad Codi:s(Le.,.cod hazartou-wasteitreater ent disposal;and raoyaing"msl <br /> Uj <br /> 20 Da ignated Facility Owner or Operator.Certification of iecaipt of hazardous materials covered by the manNest except as noted in Itsm.18a <br /> PrintedfTyped Name r 7m Signature i month Day Year <br /> EPA Form 8700.22(Rev,3.05) Previous editions are obsolete. <br /> DESIGNATED FACILITY TO GENERATOR <br />