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Please print or type.(Form designed for use on elite(12 itch)typewriter.) Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1.Gansrator 1D Number 2.Pago 1 of 3.Emergency Response Phone anlfesl Tracking Number{� <br /> WASTE MANIFEST f r r i "< <br /> t1 ars 1' )ar t i7?; 01-17 6, <br /> 80 FLE <br /> 5.Generator's Name and Mailing Address Generators ske Address(d different than mailing address) <br /> Generator's Phone: a=.r°3i:1• 3;F <br /> 8.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> Designated adtity Name and its ress U:S.EPA1D Number <br /> i } .•sa(i <br /> Fadi' s Phoni a,44A-A L�1 <br /> 9a, Ob.U.S.DOT Description(including Proper Shlpp!ng Name,Hazard Class,10 Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(d enY)) No. Type Quantity Wtivol. <br /> r ,P' <br /> 1. <br /> i 3, <br /> 4. <br /> 14.Special—Handling Instructions and Additional Information <br /> F;,_G,GLrN(,, l { RAJLCAR NO ) <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION;I hereby de dare that the contents of this consignment aro fully and accurately described above by the proper shipping name,and are loss*,packaged, <br /> marked and lebadadlplacarded,and are In all respacts in proper condition for transport according to applicable tntsmatlo"I end national gavemmentai regulations.If export shipment end lam the Primary <br /> Exporter,t carlify,that the contents of this consignment conform to the terms of the attached EPAAdmaviedgment of Consent. <br /> I ce"that the waste minimization statement Identified In 40 CFR 262.27(x)(ff i am a large quantity generates)or.(b)(If I am a small quantity gegarator)is We. <br /> snerato ero(a Phriwayped Name Day ear <br /> ' <br /> _ h t s <br /> 16.Iniematbna!Shipments ❑Import to U.S. ❑Export from U.S: Part of antry(eft <br /> Rt22prter nature for exports only): Data leaving U.S.: <br /> 17.Transporterftrmiedgment of Receipi of Materials <br /> rensparier 1 nn ypsd Nems ne re ser <br /> Ile <br /> ij <br /> Z Transporter 2 Prinledityped Nama nes rs Month Day Year <br /> 16.Discrepancy �—t �-tt <br /> 16a.Discrepancy Indication Space ❑ Quantity 11 Type 0 Residue ❑Partial Ra**n ©Full Refection <br /> Manifest Reference Number. <br /> 16b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> V <br /> Fadli s Phone: <br /> 16c.Signature ofAttamate adtdy(es eneratm) Month ay Year <br /> cC <br /> 19.Hazardous Waste Report Management Mathod Codas(i.e.,codes for hazer&&waste haabi-1,disposal, <br /> and rocyd!ng systems) <br /> 4. <br /> 20.Designated Fad(ity i?xnar or Qparator:Cgrti5catlon of receipt of tiazaldous materials cgveratl by the.manitaet except 6a ivied In iters t6a <br /> PrinteCyped Nama „, Signature <br /> }�^ th ! <br /> EPA Form 6700.22(Rev:3--65) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />