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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 1.Generator 10 Nu her 2.Page 1 jf3.Emergency Response Phone 4,lean at rackiinpg Number J <br /> WASTE MANIFEST r . i_tlftflr_i5 g';r f §t�a' -c:?? f 1� <br /> 5.Generators Name and Mallinq Address GeneraWs Site Address(it dftmtthan mailing adrasa) <br /> t.�3's�_a^�.:sA.L,St'�P�r�'a"C1.. ��1t1��ftd8tr;f~ra&tNtr?ti0i1 <br /> Generator'sPhona: <br /> 6.Transporter 1 Company Name U.S,EPA ID Number <br /> z. x <br /> 7.Transporter 2 Company Name U.S.EPA ID Numbe?"" <br /> Dosnsted FaciftyNamme and Site Address U.S,EPA ID Number <br /> c"t•FSC t '1 l C 2201 01 <br /> illi'�'e ay-123 - <br /> Fadis Phare Y-'444•4 _ rag C'ar avi,UF a45-46 Ups <br /> 9a. 9b•U.S.DOT Dosaiptlon(including Proper Shipping Name,Hazard Cuss,10 Number, 10,Containers 11.Total 12.Unf 13,Waste Codes <br /> HM and Packing Group(Ifany)) No. Type Quantity Wi Nol. <br /> 1, <br /> d :F.y-rc,?_,5:*4 r'1: '»I€..S„r..;G3;.� ;�Y.+-t f 6=.� 'L#.1 kN r"t..7V P I VYtA#lC` ) trrr n 3 <br /> Ul <br /> W 2. a� , <br /> 3. <br /> 4. <br /> 14,Special Handling Instructions and Additional In p <br /> ECM PMaW 4041 1 , <br /> 15. OENEt2ATOR'8tQFFEROR'8 d: iCATIQN:1 ttiarehY declare trust the,Cor1te11p ofHls aiitYlgnmerst sr®fuly and. above by Etre proper shipping name,and are classified, , <br /> marked and labaledlplacerdad,and are In all. In pmpar condition for heitspod aaaorrknq b applfa bis k tanegonataod national govemnwial regulations.if export shipmant end I am the:Primary <br /> Exporter,I ca*.that the oontaPits of Oft conslgnmeht mnf6an to the terms 6df* attichedEPAA"kte0 Df Cm enj&t, <br /> (certify that the vresto mhsirtionLsrnent klsn8fieii m 44CFit 26227{s}{H I`em s iarys 4Y )o!;@}ifi) (QcanY 98nerata)is true. <br /> onara a n - UignSaUtSon ear <br /> r w Gr j °r <br /> 18.katemat ensu Shipments <br /> I- ❑ewn to U.S. FlExpon frau U:S. Part of entryloxih <br /> TmnsELwsnatum .e Oats lea U.S.: <br /> Ir 17.TransprMer, snCof RecaEpi of Mater9ab <br /> ransporter 1 ems re y ear <br /> ransparfer2Pdn ypad Name r <br /> 18.Discrepancy <br /> 18a.Discrepancy indication Space <br /> l J Quantity LJ Type ❑Residue LJ Pardal Rejection Ful Ra(ac8on <br /> Mattitest Reference Number: <br /> 18b.Alternate Faddy(or Generator) U.S.EPA ID Number <br /> v <br /> ti Faraf s Fhona: <br /> 180.Signature ofWiamate Faciflq{or Generator} Month Sy Year <br /> t9:HazarcWus Waste <br /> Report Management Method Codas(i.e.,codes for hazardous waste tmstmsr k disposal,and recycling systems) <br /> 4.f <br /> 20,Miiinated Facility Owner or Operator:Certification of mosipt of hazardous materials caxared by i7ie manifest 6koapt as noted in Item 113e <br /> Pt ntedtfyped Narrre nature <br /> �y Month Day Year <br /> EPA Form 8700.22(Rev.3.05)'Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />