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Z7 - <br /> 1 <br /> Please print or type: (Form designed for use on elite ( 12-pitch) typewriter:) — Form Approved. OMB No. 2050-0039 <br /> UNIFORM HAZARDOUS 1 . Generator ID Number 2. Page 1 of 3. Emergency Response Phone 14. Manifest Tracking Numbed C <br /> WASTE MANIFEST ' / i a 10 efa " " �f �l LJ I— LE <br /> 5 Generator's Name and Mailing Address Gewator's Site Address (if different than mailing address) <br /> vcyu7ir�r CxN1 X) 4, <br /> Generator's Phone. ? ? uay ' <br /> 6. Transporter 1 Company Name U.S. EPA ID Number <br /> 7, Transporter 2 Company Name U.S. EPA ID Number <br /> 8, Designated Facility Name and Site Address U.S. EPA ID Number <br /> A A 5 "YG' <d , <br /> FA) C 0f7 ) tis " , <br /> Facility's Phone: ;Vb� F3 " 6 r, A e. coo ss " , <br /> ga. 9b. U .S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10, Containers 11 . Total 12, Unit 13. Waste Codes <br /> HM and Packing Group (if any)) No. Type Quantity Wt.NOI. <br /> z 2. <br /> UJ <br /> ad r <br /> 3 i t <br /> ( <br /> 4. 1 <br /> L <br /> 14, Special Handling Instructions and Additional Information ` <br /> n <br /> t10i . . <br /> . -7 . ,• r d � 3 < r �s , � • - <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, and are classified, packaged, <br /> marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international 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 EPAAcknowledgmentof Consent. <br /> I ,certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generatoj or(b) (if I am asmall quantity generator) is true; g <br /> Gene'atoYs/0fferor's Pnnted(r ped Name ' gnattir r ' { onto= %a_yr ear <br /> 16. International Shipments <br /> H 0 Import to U.S. ❑ Export from U.S. Port of entry/exit: <br /> z <br /> Transporter signature (for ex orts'only): Date leaving U.S. : <br /> w 17: Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name } Signatur .� Month Day Year <br /> CL <br /> M Transporter 2 Printed/Typed Name Signature Month Day Year <br /> a <br /> 18. Discrepancy <br /> 18a. Discrepancy Indication Space .' El Quantity ❑ Type ❑ ResiduePartial Rejection Full Rejection <br /> ❑ <br /> Manifest Reference Number: <br /> Fr 18b. Alternate Facility (or Generator) U.S. EPA ID Number <br /> uFacility's Phone: <br /> Lo 1,8c. Signature of Alternate Facility (or Generator) Month Day Year . <br /> Q <br /> z <br /> 19. Hazardous Waste Report Management Method Codes (Le. , codes for hazardous waste treatment, disposal, and recycling systems) <br /> 0 1 . 2 3. k 4, <br /> 20, Designated Facility Owner or Operator: Certification of receipt of hazardous matefials covered by the manifest except as noted in Item 18a r <br /> Pnntecirryped NameSignature s "' Month Day r YYee'yar . <br /> 1Z <br /> o + s 'y �. .«d' `` .s^' '' ✓ ice'-+'-'' <br /> EPA Form 8700<22 (Rev. 3-05) Previous editions are obsolete £ • DESIGNATED FACILITY TO GENERATOR <br />