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3 Form Approved.OMB No.2050-0039 <br /> printor typic.(Form designed for use on elite(12-pitch)typew(ter.) <br /> 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Mani@f'e�st Tracking Number <br /> UKIFORM HAZARDOUS v r.(,5i(ti� °fir r:lr; t e 510 A?,��(:. �j.�1 ed o.Q� JJK <br /> WASTE MANIFEST <br /> 5.Generator's NamYt a d Halling Address Generators Site Address(if different than mailing address) <br /> ^Cc:I;I;a;CsrY'SCFa'Y t4'eV F t9(C1r'iLl:l isfl. <br /> �flf.?i is�'i�1,tiik!'1,rt <br /> Generator's Phone: LS' - } <br /> U.S.EPA ID Number <br /> 6.Transporter 1 Company Name <br /> C :t !J;?t!3 h-2"Zi U <br /> U.S.EPA ID Number <br /> 7.Transporter 2 Company Name ; <br /> r <br /> U.S.EPA ID Number <br /> 8. esJgnated acility Name and Site Address <br /> :����rlw y..l N!VlthYl LPF�(1f Cki'04.01:1i_ti'2' a <br /> 1 <br /> }.31tei3rl t-Y4 <br /> Facility's Phone: <br /> 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> ga• No. Type Quantity Wt.Nol. <br /> HM and Packing Group(if any)) gI <br /> 1- {`}e}?V lit.A A bi'91af el0 YDS V-hate'Iik1 d ELt Sed t�„all} k g C7 <br /> _, _._— @ -.--•_ <br /> W � � <br /> W 2. <br /> 3. <br /> r 68 4 3a' gt €.GB 6' rife, ' 'has pore.l v dd th o <br /> An! 51 ZOLA 7 <br /> -Ft <br /> 4. <br /> t $ <br /> 14.Special Handling Instructions and Additional Information <br /> �t u-`.f-f i�(,(':f,F .. <br /> D <br /> 15, GENERATOR'SIOFFEROR'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 international 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 EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement Identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a Wall quantity generator)is true. <br /> Signature - - Month Day ;,.Year <br /> Generaiofr�fslfOfffjJrap4rs Prin�yfjped Name. <br /> rf <br /> _n 16.International S)fipments Import to U.S. ❑Export from U.S. Port of entry/exit <br /> ZDate leaving U.S.: <br /> Transporter signature(for exports only): <br /> L 17.TransporterAcknowledgment of Receipt of Materials e <br /> � <br /> Signatuf4 " * Month Day Year Transporter 1 Printed(fyped Name �,.,.,� � g7� ,/' ,r <br /> O .+•" }'`'" C--' r d -µ'�i$'S''R.•'i 1,.•/ •. '•'""F'"s9''f.•.�'J'a,.e..".."......-. <br /> Month Day Year <br /> Transpp r 2 Printe!!T ped Name ��� Signalu 1 a { ul Z <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity ❑Type 0 Residue 0 Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: Month Day Year <br /> W 18c.Signature if Alternate Faciffty(or Generator) <br /> a <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(Le.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1 r 2 3 4. <br /> 20.DesignateFacility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1 Be <br /> Signature Month Day Year <br /> PrintedlTypad NameI.i r f j 7 <br /> EPA Form 8700-22(Rev.3-051 Previbus eliitions are obsolete. t-' r DESIGNATED FACILITY TO GENERATOR <br />