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Please or typ=Form designed elite(12-pitch)typewdler.) Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1,Generatcr ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Nu:11mber <br /> WASTE MANIFEST r 1 4i 111-56 1 7 i'! U �j 64 ,302 <br /> , F L E <br /> 5.Gerimors Nam a�sd A1ai!ing Address Generators Site Address(if different than mailing address) <br /> .��.R SIJ re Irn:F1.s - <br /> Astiu.ri i:,,rl} <br /> Generators Phone: <br /> 6.But <br /> _rter 1 Com Name r + i c U S.�E i 1WMts <br /> But fTv i illitiisl�lt•lr,it..:UitiLr)iI,— � ����� y <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 1 <br /> 8.Desig@ated!Fa5ity Name and Site Address U.S.EPA ID Nurrber <br /> ?dip}h .rit'r s rw , sli. ,I <br /> it relic fd`�il!.t i!.'. <br /> Fad;ity's Phone: <br /> ga. 9b.U.S.DOT Descripan(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Ccdes <br /> HM and Padding Group(if any)) No. Type Quantity WI.Ncl. <br /> O (ticytt (1l-(fNid;sl•3i'tlrl+i`• 1'',riaE-:,r.Ne! f(►r!(1fl41 t <br /> 3. j <br /> i <br /> I <br /> 4. <br /> s ' <br /> 14.Special Handling Instructions end Additioral Information <br /> t^.n'AR 1-114- 4 t I 1 <br /> 1'rt>No. 0 r.h:(( l 01—id(.Y G1,AgI/\i.": . ,f 1 ti�[Ofj;:.t: <br /> 15. GENERATOR'SfOFFEROR'S 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 /> marked and latse!edlplawrded,and are in all respects in proper condition for transport according to applicable Intematonal and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 26227(x)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generators+ erors not yped ame igna ure onto ay ear <br /> J 16.International Shipments <br /> I— ❑Impart to U.S. ❑Export from U.S. Part of entrylexit: <br /> z Transporter signature for exports only): Dale leaving U.S.: <br /> 10: 17.Transporter Acknow'edgment of Receipt of Materials <br /> I-- Tian porter 1 Pr�'fltedfryped Nama Signature ort ay Year <br /> Oa .ti' (ItltQilt'ti <br /> QTransporter Pdntedrfyped Name signature Month Day YeaT <br /> rY <br /> r <br /> 1 B.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> I So.Alternate Fadiry(or Generator) U.S.EPA ID Nsxrsber <br /> J <br /> v <br /> LL Fadi s Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> HIS.ttazatdous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> C3 t. 2. 3. 4. <br /> 20.Designs ed Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Nmedrryped Name Signature Month Day Year <br /> EPA Form 8700.22(Rev.3.05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />