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A <br />eaae pint or type. {Form +3astgnod for use on elite (I2 -pitch) typeiurii,.t) <br />Form Approved, OMB No. 2050-0039 <br />ff <br />UNIFORM HAZARDOUS <br />r <br />1 Generator ED Nurnkx,r 2 Page V o, <br />3. �rrergency Response Phare <br />' <br />Tracking Number <br />d. A�aarifest S �n I <br />� <br />y K- <br />WASTE MANIFEST4 <br />3 ;_ �, tt <br />5 Generator's Name and Ida=ling Address Generator's S:ie Address ti" different than mailing address) <br />Getiera`oes Phone <br />ri Transporter 1 Company Name <br />U.5 EPA IDNumber <br />d.Tanapoier?Corrpt y9Ydne <br />U.S_EPA IDNumber <br />€ tri zated Fool �Yy { snta a tt 5rte nd2fPes <br />U S, EPA ID Ntim,'.er <br />Fa;"ility s Phone: <br />'. <br />wa <br />5o U S. DOT Description (mciuding Proper Shap ng Na.re, Hazard Class. ID Numtrar tfs. Container; <br />1#. Tota' 12. Unit 13, Waste Codes <br />HkI <br />and Paccin=a Group lipany)I No <br />Type <br />Ouantat Wt Nlcl, <br />0 <br />2 <br />LLJt <br />t a Spe:aal Hdrtdiirg Instresc'lons and Additional It+fcrma¢ion <br />„•, ,> <br /><.5 GENE TOR'SlOFFEROR`S CERTIFICATION: I hereby declare that the. contents of this cor4signment Are* ,,illy and accurate;y described ab:lve by the propeP e ppsna narne. and are classified, packaged, <br />la=ced and Iabela ilpiacarded, and are in all respects an proper o*undibim for transport accordt ag to applicable, interna flora. a:,,d minora; governmental <br />regulations, if export sh!prilsnt and I am the Primary <br />Exporter, I certify that the c*ntents of tits consignment conform to the terns of the atiachred EPAAck'nawledgmen, n Consent. <br />I ce.,14 that the waste mmmmization statement identified in 40 CER 262.27(a) (I I am a large psanJiy gena r) or 1b. (d 1 ars; a small puaritty <br />generator) is truc- <br />Gertera',o'slONemes PantedlTyped Name Signature <br />Month Day Year <br />a i6. in''6mationalShipments �� <br />Impar? to U.S 4 1 Expc it front U.S, Pct nt entryxitm <br />Tran p f signature (for exports only;: Date leaving U.S., <br />W 17 Transporter Ackn,vledpient of Receipt of Materials <br />Trac, porer I PPriniedavF; Name <br />may= year <br />0 <br />€e)... <br />Transporter 1 PrrnKedil'ypaed Nance $Pgna#ure <br />„ <br />hAanth Day Year <br />.8, D8 crepanry <br />--� <br />18p, D.sorep ahoy indicaboi Space Quantity Tpe El Residue <br />� <br />1..,._d Partrai Rpie,,ton t_ Full Rejection <br />Manifest Pplerence Number: <br />I Bio Alternate Facility {or Generator) <br />U S EPI; ID Nuniber <br />#„8 <br />Faoa r y`s Phone: <br />LO 18F, Signature of Allernate Facility (or Generator.) <br />Mor th Day Year <br />19. Hazardous, Waste Repel Management Method Codes (i.e.. code, far hazardous svastri, treatment, dtsP sal, and tecyekng systeans) <br />55 <br />UJ 1 2 <br />20 Des -i .atoid Farifity, Nner or Operator: Certif4stfon of receipt of hazardous materials prrvered by the ma est except as noted in Hem 18a <br />-year <br />PAntedGTyped Name Sjgnatasre <br />hfanth Day <br />EPA, Forin 8700-22 (Rev. 3-05) Previo.Is editions are obsolete. <br />,,Et-,4EV0:T0FVE, INITIAL COPY <br />