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L F Please grin!Or -0 � i <br /> type.(Form designed gned far use on elite(12-pitch)typewriter 1 O � <br /> Cl) UNIFORMNAZIRDOUS I Generator In Number <br /> Form Approved.OM91 2050-0039 <br /> Q WASTE MANIFEST 2 I'a9P t ni 3.Emergency p,-.,,,,r,,;,_phnne 4.Manned Treeklny NVm6er I' O O C <br /> z $.Generate,r'e <br /> -aril M.,r, ^' 1 11/ i O .< <br /> gAddress JJK UJ <br /> U/ GaneratoYs Sile Aptlrets IH diH¢rent than maAing adtlrnsal r <br /> D C O <br /> rn <br /> D Generatvfs phone O <br /> z 6.Transporter 1 Compan4 Name 0 _ <br /> � U.S.EPA l4 Nwnbr•r <br /> 7.Trenspener Z�.ornpam Name zT <br /> US.SPA VO rlumtier tL <br /> N (D <br /> 6 Oesatad gnF,',I,)Name and Sae Address 0)U 5.EPA la Number <br /> SZ <br /> O <br /> C <br /> Ln <br /> Fadlity's Phone " C <br /> ga 9b.LLS-0070escnptinn p::r4,.:irrr_1 Proper Chipping Name.Hazard Class.In Number, Conlamers a)10. <br /> HM and Packing Group nr anvil No. Type Quantity WT ivuo 11 t3.waste Codes rN+ <br /> 1 <br /> (D <br /> o 3 <br /> rY 7 <br /> ur <br /> w rD <br /> t7 <br /> Ln <br /> rrt <br /> O <br /> 3 V <br /> tT <br /> t.D <br /> 01 <br /> N <br /> A � <br /> 00 <br /> 14.Special Handling tnstructions and Additional Information O <br /> cr <br /> (D <br /> 1< <br /> Q <br /> 15. GENERATOR'S10FFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,anti are classified,packaged, <br /> marked and labeiedlplacarded,and are in ail respects in proper condition for transport according to applicable international and national goyemmental regulations_If export shipment and I am the Ptimary r•r <br /> Exporter.I certify that the coni of this cnirsignment conform to the terms of the attached EPA Acknowledgment of Conant. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(41 am a small quantity generator}is We. OC <br /> Generalor'slolferoi tonotedlT Name Signature <br /> yp� 9 Month Day rear <br /> Q <br /> 16.Miremarionaf Shipments (D <br /> Li Impart to U 5 El Export from V.S Port of enliylexit: �• <br /> Transporter signature(for exports only): Date leaving U S. C <br /> I 17 TmnsporterAcknoWedgmeni of Receipt of Malenals <br /> Ll <br /> rt <br /> Transporter 1 Pdnted(fyped NameSignature Month Da} year Q <br /> 1 0 <br /> O <br /> Transporter 2 PnntecifTyped Name Signature Month Day Year -0 <br /> Y <br /> 18.Discrepancy <br /> 18a-Discrepancy Indlcalion Space ❑ Quantity ❑Type ❑Residue ❑Padral Rejecbnn ❑Full Rejectier, <br /> Manifest Reference Number. <br /> r 18b.Alternate Facafity(or Generator) U.S.EPA ID Number <br /> J_ <br /> 1 <br /> L Facility's Phone' Month Day Year <br /> 18c Signature ofAlWrrrate fastllry(or Generator) <br /> ((D <br /> 7 15 Hazardous Waste Report Management Method Codes(i e,codes for hazardous waste treatment,disposal,and reltyoling systemsl O n <br /> 4Q O <br /> Li1 2. 3. Q <br /> .. <br /> 20.Designated Facility Owrter or Operate►:C,mti�On d naelpl of fterrxdous covered by the mendest except as noted In Item 1 Be Month Day ymr C2 k <br /> —Sigmature < � <br /> Prim yped a �] <br /> O <br /> v <br /> GENERATOR'S INITIAL COP) W <br /> (D AForm 8700: (Retr,.345): !F DA�4Male1�. rn <br /> N <br /> O <br /> W <br /> O <br />