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J <br /> ease print or type.(Form designed for use on eine(12-pitch)typewriter.) Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2.1 1 of 3.Emergency Response Phone 14.,MantW Tracking Number <br /> WASTE MANIFEST <br /> 5.Generator's Name amdffaAngAddress Generators Sita Address(1f different than mailing address) <br /> tF3£:tS r31r4 t K��4+ <br /> Generator's Phone: tr s'A;1 ;r. <br /> ransparter 1 mpany N ams U.S.EPA ID Number ' <br /> t)llE�rt't t'�, ts13t llYriyG tr7 <br /> „ ;ryT;g t f.iQr£jag� <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Faciily Nama and its U.S.EPA ID Number <br /> t� 7I s�t�i� rlrt <br /> 34 r,W <br /> y n a x h <br /> FadtitJsPhone`�i-�I�=�dE,; r:�.t h.;4f�rr1,�t �utdll�d�. ' <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Nam-,Hazard Class,ID Number, 10.Containers 11 Jotal 12.Unit' 13.Waste Codes <br /> HM and Packing Group(rf any)) No. Type quantity Wt 01, <br /> RR ' <br /> r i ss <br /> tq ,qwd .tom su. 1. :'tO'E1 <br /> , <br /> rL 2 <br /> W <br /> 4. r <br /> 1 <br /> 14,Special Handling Instructions and Additional Information —' <br /> 1#? "1" P.•`rfl.4:.kW. {+:S �.l �� � 'l,f<�7 <br /> I?=9th t,t � �YifstETtl�r9s?..sa 1. <br /> 15. GENERATOWSiOFFEROR'8 CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified;packaged, <br /> 1 marked and labeladlplacarded,and are in all respects in proper condition for 7an4*d accardGhg to applicable intematlonal and national governmental regulations.If export shipment and I am the Primary <br /> i Exporter,l tartly that the contents of this consignment conform to the tenns of the attached EPAAuamowledgment of Consent. <br /> I certify that the waste minimization statement Identified in 40 CFR 262.27(a)(if I am a large quantdy generator)or(b)(ff 1 am a small quantity generator)is true, <br /> enerator s rn ams titgnsture wui Dagy---Ve—ar- <br /> -j 16.IntematienalShipments <br />( 1- ❑Import to U.S. Expert from U.S. Pot of entry/exit _ <br /> I <br /> Trans222r signature fore its only): Date leaving U.S.; <br /> W 17.TransprvtarAckrnrr4edgmentofRemiptofMaterials <br /> LU <br /> I Transported PrintedrTypad ens _ Month fay ear <br /> I <br /> Tzar sporer2 Pdntedliyped Nam Signaturethth a�r <br /> 16:Discrepancy <br /> 18a,Discrepancy Indication'Space ❑ ouant I—I <br /> ry �Type ;-.._}Reaklue ❑Partial Rejection ❑Full Rejection <br /> Maridest Reference Number: <br /> 18b.Alternate Facility(or Generator) �� U.S EPA'ID Number <br /> Facilitys Phone: <br /> 18e:Signature of Alternate Facility(orGtmeralor) Momh Day' Year <br /> 19.Hazardous Waste Report Management Mothod Cates(i.e.,codes-for Hazardous waste treatment,d sposal,and racycling systems) <br /> ®, 4, <br /> 20.Designated Owneror0 <br /> g Facility Forster:Certification of receipt of thazardom ntaterals covered by the manifest excapi asnoted in ham 1t3a <br /> Pr n ypad Name Signature, Month ''Day Year <br /> EPA Form 8700-22(Rev.3=05) Previous editions are obsolete. TRANSPORTER'S COPY <br /> i <br /> I <br />