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Please print or type. (Forth designed for use on elite (12 -pitch) typewriter.) <br />UNIFORM HAZARDOUS 1. Generator ID Number 2. Page;1 0 <br />WASTE MANIFEST (":f;a,.,t1f+•3'.;. <br />5. Generator's Name and Mailing Address <br />`:i"ft:°3i's�4�Y1 ,�i.��f.yw €;r, iGt•$� <br />Generator's Phone: ryt 1 <br />6. Transporter 1 omrpany Name <br />7. Transporter 2 Company Name <br />f,N' <br />r <br />B. Designated Facility Name and Site Address <br />Facility's Phone: <br />9a. 9b. U.S. OOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />HM and Packing Group (if any)) <br />� 1. �/€���'� t•�$, ckhi F'i�Ff ¢tt`S l��l ��.-!i� t?�°;-. �r d���g 1, �.�n'3 <br />L1J <br />(LLD, <br />4. <br />Form Approved. OMB No. 2050-0039 <br />es ojse Phgpe 4. ManifesE Trackin Number <br />E FLEI <br />U.S. <br />• r i. , :„ri?,.';Pfd i}'� 4ft :,u i. t,�i <br />10. Containers 11. Total 12. Unit <br />No. Type Quantity Wt.N01, 13. Waste Codes <br />p''�'6 fi-e"_�0 4 <br />3s l.I K y,'W;i410 $Vt,�e +4r c rr F1'[^#• iii .�'°” t bY.,(: >✓ i$`,r <br />i.ziltt^f �� i f5: 1sF_ tl'•;'i.�'f•«�' f�,Y r�'-�t 3i. i'ln�i'���tr!# t �I,`f it�rin•$i ;fit? k".r`:d%yfb;�....�r,"a'; 9�$ai §t ."f•'�'�s�41f3�, <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br />marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable intematronal 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 EPAAcknowledgment of Consent. <br />I certify that, waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />Generator'sl0fferoes Prtrfed yped,Name ' f <br />Signature <br />Month ay <br />4 16. International Shipments <br />❑ Import to U.S. �ry ❑ Export from U.S. Port of entrylexit: <br />Transporter si nature for exports onq: Date leavrn U.S.: <br />ti <br />17. Transporter Acknowledgment of Receipt of Materials <br />F ... r <br />18, Discrepancy <br />16a. Discrepancy Indication Space <br />❑ Quantity El Type ❑Residue <br />18b. Alternate Facility (or Generator) Manifest Reference Nur <br />'J <br />V <br />Q <br />L- Facility's Phone: <br />w 18c. Signature ofAlterrate Facility (or Generator) <br />a ' <br />Z <br />W19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />D 1 • 2. 3. <br />20. Designated Facility Owner or Operator: Cortification of receipt of hazardous materials povered by the manifest except as noted in Item 18a <br />PrintedTFypsd Name Signature <br />EPA Form 8700-22(Rev. 3-05) Previous editions are obsolete. <br />Y <br />❑ Partial Rejection <br />U.S. <br />4. 1 <br />❑ Full Rejection <br />GENERATOR'S INITIAL COPY <br />