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a J <br /> Please print or type (Form designed for use on elite(12-pitch)typewrder) Farm Approved OMB ko <br /> 1 Generator ID Number 2 Page 1 of 3 Emergency Response Phone 4 Mamf6st Tracking Number <br /> � <br /> UNIFQRM HAZARDOUS Q�g $l�_ty v F LE <br /> WASTE MANIFESTjrAl W0210121 <br /> 5 Generators Name and Mating AddressGenerato s Site Address(it ddferem than mailing address) AFFIX TO RIGHT SIDE <br /> OF ALL HAZARDOUS <br /> pn$ '(� MATERIALS BILLS AT LIN <br /> $AIRF SAY SO TAB WILL STICK OUT <br /> J <br /> AArrA6 G C LASEl,-e0D•497 eg6a <br /> 6 ransporter o <br /> US EPA ID Number <br /> t Inc. sVy Opo <br /> 7 Transporter 2 Company Name U S EPA ID Number <br /> 8 Designat aclity Nene and Site Addressm1U S EPA 10 Number <br /> Q1eGt'ti 057870 <br /> 10 CW o 5 Ha" <br /> ac i s <br /> gat 9b U S DOT DescriptSol i -ion(including Proper Shipping Name,Hazard Class,ID Number, 10 Containers 11 Total 12 Unit 13 Waste Codes <br /> HM and Padang Group(l any)) No Type Quantity Wt Not <br /> flu UN,993.w�Int ��mo s��rftelemy(z- CIFq3S P , <br /> 0 X medlytpropyName,M .s.Pc <br /> z 2 <br /> LU <br /> 3 <br /> 4 <br /> 14 Special HancHM Instructions and Additional information <br /> 79181 DOGIII.11170t#:DMW <br /> 2EG17> <br /> 1)ER1311t ,NI&„a,sSR --001 l X IZ-6,UW MrcN1 0'0 <br /> 15 GENERATOR'5JOFFEROR'S CERTIFICATION I hereby declare that the contents of this consignment are fully and accurately descnbed above by the proper shipping name,and are classified, ck , <br /> marked and labeledlpdacarded,and are in all respects in proper condition for transport according to appucable intemational 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 EPAAdcnowledgment of Consent <br /> I certify that the waste rranimizaton statement identified in 40 CFR 262 27(a)(if I am a large quantity generator)or(b)(d I am a smatl quan generator)is true U 111 <br /> enerator'sr eror'sPnntedlTyp Namegnature on ay Year <br /> / ort ' 0VT ILiz15` <br /> tfi internoval Shipments �Import to U S ❑Expert from U S Po of entryiexit <br /> i— <br /> ? <br /> Transporter signature-fore its onl' Date leav!nq U S <br /> 17 Transporter Acknowledgment of Receipt of Materials <br /> Tra <br /> 66L4 FL a <br /> Signature, on ay 2-1 tear <br /> 6 iLlf t ffl ( on I y dear <br /> 4 Transporter 2Prnhte ped Na 9 <br /> 18 Discrepancy <br /> 18a Discrepancy indication Space ❑ Quantity ElType ❑Residue �Partial Rejection ❑FUII Rejector, <br /> Manifest Reference Number <br /> 18b Alternate Facility(or Generator) U S EPA ID Number <br /> J <br /> U <br /> Facii s Phone Month Day Year <br /> 18c Signature of A temate Facility(or Generator) <br /> Q <br /> natur <br /> 19 Hazardous Waste Report Management Method Codes(i a,codes for hazardous waste treatment disposal,and recycling systems) <br /> G 1 2 3 4 <br /> 20 Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the mandest except as now in Item 18a h Y r <br /> ll � <br /> PnntedlTy �&, I b A& Si n <br /> 1 'U WWI <br /> EPA Form 8700 Rev -05 Previou dltt s re obso ete 41V34ES11bGNNAAFA60rOT6 DESTINATION STA E(IF REQUIRED) <br /> 160938-114918-1 <br />