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Please print or type:(Fned for use on elite .itch <br /> 9 12-pitch) emlegifrr deal 12 VM 71 ., <br /> r.} <br /> UNIFORM us e r ID Number Form � <br /> 2.Pie 1 of E <br /> I. WASTE tFEST . jePon� 4.Mardfest Traekin Number <br /> '1 y� <br /> 5.Ganeratoda Mallin r� 1 �r_ 3 <br /> Geaeratoi's Site Address(d dHF�t than mailing •6r <br /> 8.Transporter 1 Company Name <br /> U:S.EPAID <br /> 7.Transporter 2 Company Name l�t 1 <br /> U.S.EPA tD Number <br /> 8.Designated Fadgty Name and Site Address <br /> 05 <br /> #- <br /> Fadfi s Phon rr ] <br /> .0 <br /> 9b.U,$.DOTDes <br /> 9a aiPt C+ndurNng Proper 5h�ppinq Narne,Hazaid Class,tD.Nuber,.m <br /> . FMq. andPeddngGrotrPCdamU , . .. .Cohmtntxs:..f ,0 11:Total 12.Uist <br /> 1. 1•A r'1 ( }. No. Type QuarWly WI.W. I&Waste Codes <br /> fL <br /> ( f <br /> 3: Eg 2016 <br /> 4. NV <br /> II <br /> A TV Ra'P <br /> 14.S He t� Instructiar�sandgddfgor�aih�formation <br /> 15. GE,NERATOR'sfoFFEROR'S CEIMFICATioN:Iof C" <br /> marked and labeled)lacard and are at ati hereby declare that the txmtenLs.of this consiggmegt are fidty and accafa�fy described atmve by the proper shippiry1 name,and are dassitied,Packaged, <br /> P respects in proper condition for transport according to a <br /> Exporter,l certify that ft conter�of gds g applicable IMemOftal2rid nabonetgommmenral regulations.Ne <br /> 1•derttfy thatthe waste mktimfzatbn statement)dentifiedi CFR262-27(a)(lm to the term of fit arn�died nt of Consent N shipmerit•and I am the Pdrrmry <br /> Generate s-Fr�at yped(Noma• a large Q SY 9ene►Stor)or(b)(LTi am a sr 0 9uantity genmator)is ban. <br /> 9longr Qay Year <br /> 18.International Shipments <br /> OImport to U.S. T+ <br /> .Z Transporter signature(for exports only): LJ Export from U.S. Port of enbWe* <br /> 17.Transporter mof. torma DatervingU.S.: <br /> Transporter . DPed <br /> NY <br /> Q twnsporter2Printed)I'yped(umrre •• �•��°''� "7 Y <br /> Signature •...? <br /> month Day Yea¢ 1 <br /> 18,Discrepancy ! !� <br /> fBa.Dbpepancy tndloetion Space ❑Quantity 0 <br /> i! <br /> ❑Partial Rejection ❑Full Rejaction <br /> Agert►Ete Fadidy(a Generator) Mardfest Reference Number ry <br /> U.S.EPA ID Number <br /> Fadtilys Rhone: I <br /> 1 Bc.Signature of ate Fa (or Generator) <br /> �.. Day Year <br /> t 19.Haiardons Waste Report Management megmd Codes(r.e.,codes,for hazardous waste bsatmenk di al,and re r <br /> 9 systema) JP' <br /> 1. 2 <br /> 4. <br /> 20.Designated FadCdy Owner or Operator.Cergfigripn of receirN hazardous materials covered <br /> ri Name by the manifest except as noted In item 188 <br /> 1 <br /> • aignsixine <br /> ar <br /> 1 Form 8700=22(Rev.-3-05) Previous editions are obsolete. <br /> TRANSPORTER'S COPY <br />