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r <br /> Please print or type. Farm designed for use on elite(12-pitch) <br /> ( g typewriter,) Form Approved.OMB Na. <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2.Page 1 of 3.Emargerq Response P=010631930 <br /> nHaat Tracking Number " <br /> WASTE MANIFEST "1.:3` x a;?€ r.), 3.�r;7 <br /> i_..E <br /> 6,Generator's Name and Mailing Address GenaraWs Site Address(f ditmt than mailing address) V <br /> 6 <br /> oar"_ <br /> GanaratoPs Phone: <br /> ranspor0-11-Company Name <br /> U.S.EPA ID Number <br /> 7,Transporter 2 Company Name U.S.EPA 10 Number <br /> 81 Designated Facily Name and Site Address U.S.EPA ID Number <br /> a7r�, i.z E <br /> l ash¢.. <br /> Facility's Phone." <br /> ga, gb.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10,Containers 11.Total 12.Unit 13.Waste Codas <br /> HM and Packing Grcup(If any)) No. Type Quantity WtNol. <br /> Q ,, ...r. t £c.�� � x 3 3 fA F'> <br /> W 1. I <br /> 4. <br /> 14.Special HandGrg Urs n eticns and�.ddt oral lnfannat an __ <br /> 1 <br /> tri <br /> i <br /> 15. GENERATOR'SiCFFERQR'S CERTIFICATION:I hereby dedara that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and tabalydrpfacardad,and are in all respects in proper condition for transport according to applicable international and national go>remmentat regulations.if export shipment and I am the Primary <br /> Exporter,I cenlfy that the contents of this consignmerd conform to the terra of the attached EPAA&r4wiedgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(it I am a large quantity generator)or(b)(if I am a small quantity generator)is true, <br /> nerato s1 erx s nnl yped Name bhgnqture Month Day--w-aw <br /> 77-1 �.�. . ��,. .�. .�7 <br /> ..r 16.International Shipments <br /> ❑import to U,S. ❑Export frim U.S. Port of entry(axft: <br /> Transporter sklmiture for exports only): Date leaving U.S.: <br /> Ce 17,TranspodarAdmowledgment of Receipt of tlatedalsUj <br /> ' <br /> Transporter)Pdntedltyped NbtmaMontha y <br /> Wear <br /> Transporter 2PrinteWIYP dNam � by � Year <br /> Signature Ut ayy Year <br /> e•- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity Q Type t-_)Residue ❑Partial Rejection ❑Full Re)edisn <br /> i <br /> Manifest Reference Number: <br /> ma <br /> 186.Aitele Facility(or Generator) _ U.S.EPA 1D Number <br /> J <br /> LL Fadi s Phone: <br /> w 111c.SignatureofAltemaPadlity(orGeneraior) Month Day Year <br /> qS <br /> z <br /> I 19.Hazardous Waste Report Management Method Codes(i,e.,codes for hazardous waste treatment,dis)osal,and recycling systems) . <br /> G 12, 3, 4 <br /> 20.Designated Facility Owner or Operator:CerGfcatlan of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrintadlTypad Name Signature r <br /> )"mss � Mion01 Day Year a <br /> EPA Form 8704-22(Rev.3.05) Previous editions are obsolete. D9§IGNATED FACILITY TO GENERATOR <br /> I <br /> r <br />