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F . F. IF R. 1%, " W. RN1 111 <br />lease <br />print or type. trurrn <br />i Generator ID Number <br />2. Pap I of <br />3. Emergency Rowse Ph— <br />4. what - a Trading Numberr <br />UNIFORM HAZAR 0OUS I <br />JJK <br />WASTE MANIFEST L�0!4A'- <br />011279087 <br />5. Generators Name and Mailing Address censralors site Address (if dtforart: Man mailing addresa) <br />�4&IFISLA,,Y �v Tt <br />Generalor's Phone: U.S. EPA ID N~ <br />6. Transporter I Company Name <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Desi Hated FIrty Nanceand Ske Address U.S. EPA ID Number <br />Facilit es Phone: <br />79., <br />9b, U.S. DOT Description (including Proper Shipping Name, Hawd Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />NO. <br />Type <br />HM <br />and Packing G—D (if any)) <br />Quantity <br />VILNOL <br />0 <br />1- 'P_�N '4�VaSTI! IJIQLV tR4 <br />2. LKr _V <br />3. <br />4. <br />14. S Hareffing Instructions ancl Ackfitoinal Inormation <br />dFri v i ", I <br />15. GEN EUTOR'S/OFFEROWS CERTIFICATION: I hereloycleclare that the contents of this consoment are lVily and acewately described above by the proper shipping name, and are dassifed, padcageo, <br />marked and labeled/placarded, and are in al respects in proper condition for transport according to applicable, international and national governmental regulaborts. If export shipment and I am the Primary <br />Exporter. I cerfify that the contents of this consignment conform to the femns of the attached EPA AcKnow4edgment of Consent. <br />I cortity, that the waste minirnization statement Identified in 40 CFR 25227(a) (if I am a large quanthy generalarf of (bIl (if i am a scral quantity generator) is true. <br />Genera r's PnnWT Month Day year <br />_j <br />I— <br />16, International Shipments <br />Impat to U.S.El E from U.S. Pod of ontryfey& <br />Transporter signature (forexPorts onift Date leaving U.S. <br />W17. <br />Transporter Aciatowledgment of Receipt of Materials <br />Signature Month Day Year <br />Transporter 1 Pfl;vted(,TV Name f <br />0 <br />TQ. <br />ransporter 2 PrintodifTyped Name Signature Month Day Year <br />tk <br />18. Discrepancy <br />tea. Discrepancy Indication Spam D Type El Residue ❑ Reection Full Rejection <br />P.0 j <br />Manifest Reference Number <br />lab. Alternate Fac" (or Generator) U.S. EPA 10 Number <br />LA. <br />Fadfib?s Phoris: <br />LU <br />Month Day Year <br />18c. Signature of Alternate P;@F(or _GovaW) <br />z <br />Ddes hazardous waste treatment, disposal, and recycling systems) <br />19. Hazardous Waste Report Martagoinarit Method Codes (i.e., c for <br />3, 4. <br />Designated Facility Owner or OperatqI; CarlIfication offecoo of h5-6- materials covered by this manifest except as notatf in IMT <br />, y Year <br />Printed(Typed Name Signature Mon Do <br />Priv <br />EPA Form 8700-22 (Rev, 3-Ubj Previous ecktore are oDsotem. I MA94*tivrl I =in ;2 %Ivr <br />