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1111111111011111 <br /> Form A Aroved.OMB No.2050-0034 <br /> Please print or Type. P <br /> UNIFORM HAZARDOUS i Generate!D flu r 2.Page 1 of 3.Emetgerey Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST <br /> � « . 012494825 <br /> h-Generatoes Name ark Mating Address GeneratoPs Ste Address(it different than matte address) <br /> -di <br /> 6 Transporter 1 Company Name U.&EPA ID Number <br /> s.,ff-.r„�_.zK� rg, � _, -._ .. �.�.�. �' b,.E <br /> 7.Transporter 2 Company <br /> U.S EPA i N i nber <br /> a wc, f c tf C*� jCA R 000 1-75 -Z Z- <br /> 8.Designated Facility Name and Site Address U.S EPA ID Number <br /> Fedty`s Phare <br /> ga, 9b.US,DOT Description( %Progsr Shipping Name,Hazard Cass,ID Number, 1�(,cnfainem t,Total 17 Ung ' 13 Waste Cordes <br /> HM and Packwntl Grtvap(f any)) No Type ovantity YsuVol, <br /> 1 aAoc <br /> t <br /> �=1 in r t <br /> UA 2. N�on RCpa h87 =j jc1 (Cansurinr DF 0c00 . �b <br /> tUA d <br /> 3. <br /> t <br /> 4. <br /> 14,Special Handling instructions and Additiorat Information <br /> 15. GENERATOWSft3FFEROKS CEMIFtCATiON: I hereby declare that the ctmlents of this consignment are fully and accurately described above by the prom shipping name,and are classified,packaged, <br /> marked and latatedtptacarted,and are in all respects to proper condition for transport aow ding to applicable intemationaland national vernmentat regulations.It export shunt an d tam the Primary <br /> Exporter,I cea*that the r�taats of this con"nment conform to the s of the attached EPAAdm gment of <br /> 1 oerttfy,thet this waste minimization statement identified in 40 GFR 262-27{aj(t 1 am a targe Wantsiy gereraW)or{b}(ff i a a cured q tity razor)is tree. <br /> Sign Monte Day Year <br /> OW2:�� A.J (I <br /> 'f <br /> J 18.jKlematiDnat Ship <br /> t to Us, EFEport from U.S. Port of entrytemi: IQ <br /> zansporter signature(kir exports only}: Date leaving U.S.. <br /> Transporter Acknowledgment of Receipt of Materials <br /> ransporter IP 1df Nam Sigcsture Month Day Year <br /> 10 <br /> ct. <br /> [ � <br /> ZTransporter 2 Prtntedtfpped Name Signature Month Dray Year <br /> t- 4 S 20 <br /> 18.Fkscrepancy <br /> 183.t)scrapancy trdicalion Space 0 tUty i l Type ❑Residue ❑Partial Rejection E-1 Full Re)ectiac <br /> Manifest Reference Number <br /> 18b.Atemate Facility(or Generator) U.&EPA ID.Number <br /> U <br /> e`r+ Facility's Phare: <br /> W180,Signature of Alternate Facility(or Gerarator) Month Day Year <br /> Q <br /> Z <br /> V519Hazardous Waste Report Management Method Codas(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> Uj 1. 2' 3 4 <br /> III <br /> 24,Designated Fop' Owner or Operator.Cenixr alior of receipt of hazardcws materAs covered by the mak£est except as need in Item 18a <br /> PrintecVTyped Namd 11 Month Day Year <br /> EPA Form 8700-22(RmT 1247 Previous editions are obsolete, 4�m i�st� T' FACILITY TO EPA's ei-P ANIFEST SYSTEM <br />