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Please print or ITEM #601 pri type.(Porro designed for,'ca�(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Num r <br /> WASTE MANIFEST <br /> uALctc l ttxt t ;t : ,.>-6,�� � '.� ,�' 1 78 G B F <br /> 5.Generates Name and Mailing Address Generators Site Address(if different than mailing address) <br /> FORWARD LAMLf ILL <br /> 991-49 6 F OSTIN RLI <br /> Generator's Phone:r;, rx <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> cJr l Ji -tVVA'A f kali )I I"., <br /> 1.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> c:stt4ta t t:::tas.a <br /> 7I: i''iTt-I`,3 A,"ftll(1d#17.44:?' <br /> Facility's Phone:cJd48,a4..i(aa+i <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group('d any)) 13.Waste Codes <br /> No. Type Quantity Wt.Nol. <br /> 1. r <br /> d' P1t"t44RCRA:4A'ANf)'AJ! -dVA• rF ':t.! rI1,AlI illt-If,t°10:, i'gAf>F-R)1! ! r;a.", f' <br /> O _ <br /> f-If T R,!4 fwe®r.1t i <br /> w <br /> z 2. <br /> w i <br /> r, <br /> i . <br /> 3. <br /> i <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> I*C Flt#:it ( A1330{`I*111 Y PAK IN I-R i E lit:, t.ftlif#3 `i <br /> EMER EW,''i C0fl1,ACj t}AVk- <br /> 15. GENERATOR'SlOFFEROR'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 labeled/placarded,and are in all respects in proper condition for transport according to applicable intemabonaland national governmental regulations.ti export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAA owledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity erator)or(b)(if I am a small quantity generator)is true. <br /> Generator's/Offeror's Printed yped Name {` •- Month Dayt Year <br /> 16.International Shipments <br /> ❑Import to U.S. ❑Export from U. Port of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> jXa Trans <br /> 09dSignature. ay Y <br /> ,-A D <br /> eQf2Pdnt Name Signature Mbnth Da Y <br /> ,? <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space it ❑Type ❑ ❑ I ❑Full Rejection <br /> Quant' T Residue Partial Rejection <br /> Manifest Reference Number: <br /> 18b.Altemate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> I. Facility's Phone: <br /> W 18c.Signature of Altemate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as ruled in hem 18a <br /> Printedlryped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> TRANSPORTER'S COPY <br />