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for use on elde (12 -pitch) "writer.) <br />111 <br />urfrMl VI r I- NA <br />B. Designated Fad4 flame and Site Aldress _r <br />�Fa�cils Pti.101". <br />& U� DOT Daption (including Proper Shipping Name, Hazard Class, ID Numoer, <br />and Packing Group (d any)) <br />'n Z <br />o",,, <br />14. <br />14. Special Handing instructions ano Additional information <br />17f <br />0 -7 <br />16, GENERATOWSIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described abo"bY the Proper shipping name, and are classified, packaged, <br />marked and laded; riled, and am in all respects in proper canditron for transporn according to applicable international and national govern marltal regulations. if oxW shipment and I am the Primary <br />Exporter, I cartify that the contents of hs consignment conform to the terms of the allached EPA A 01 Consent <br />I certify, that ft wage minimization staternent identified in 40 CFR 26227(a) (If I am a large quantity gmrat&) at (b) (if I am a small quantity generator) is true. <br />Generator's/Month Day Year <br />a Printed/Typed Nam . Signature <br />Al't 1)1, <br />16, International Shipments 01.wt.U.S. El aw fr. U.S. Port of antryieXit <br />Transporter sigWum (for export, only). Date leaving U.S.: <br />17, TransporterAclonowledgment of Receipt of Materials <br />18, Discrepancy <br />11§,t0screpancy, Indication Space Eli oftantity ElType ❑ Residue U Partial Rejection tJ Full Rejection <br />Manifest Reference Number: <br />18b. Afternale Facility (or Generator) U.S. EPA ID Number <br />LL Facility's Phone: AM, Month Day Year <br />18c, Signature of Afteiiit—eFa^ for Generator) <br />19 Hazardous Waste Re rt Martagetraird Methrid Codes (i.e.. codes for hazardous waste tre~, disposal, and recYdft sYsssm) <br />1 of 2. <br />26. Designated Facility Owner or Operator- Certification Of s materials covered by the mambst except as noted in lkm48a <br />lonatum Worith <br />Day year <br />TROffy—ped Name 7 <br />Z <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. TRANSPORTER'S COPY <br />