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Please print or type.(Form designed for use on elite(12-pitch)typewriter,) <br /> Form Approved.OM8 No.2050-0039 <br /> UNIFORM 11 R€}OUS 1.Generator IIID Number 2.Page 1 of 3.Emergency Response Pbone 4.Manifest Tracking Number <br /> WASTE MANIFEST J,,- ax1" l� p� t 4 E j r'°) <br /> py5,LGenerator's Name and Mailing Address G <br /> g.tpf .n fBF <br /> Gener£®actor's Site Addressq,(if differentthanmailing address) <br /> YSS� .�9 �g "Q'�e�'� Et bs g @gg � t Y`"�H:�•�u� ��. <°�t'd #���^�yd�p kw�p�a � ffiY �.y�e,..k { <br /> kE'a 4\�N^fl�.. �-..�.:. 2:F�L�..: tpgY.'.W�a? 'd (..-�,� f/ {�''$�.o 5� ��VC,,.��.,9 �l sN`•'"a'��.`).'�3 i.✓�^b 8'^a'a M1l.,� <br /> Generator's Phone:""A <br /> -•. s <br /> 6.Transporter 1 CompanyNanie <br /> US F'Af7Number <br /> R s <br /> �. Wa13 <br /> 7.Transporter 2 Company Name <br /> _. U.S.EPA Ip;�lurbel �. 1" <br /> 8.Designated Facility Name and Sile Address <br /> •�2 ;w + �� U.S.EPA ID Number <br /> Facility's Phone: ;'•... ,° r,,,;` ' 7 <br /> ga, 9b.U.S.DOT Description{including Proper Shipping Name,Hazard Class,ID Number, 10.Containers <br /> HM and Packing Group(if any)) 11.Total 12.Unit 13.Waste Codes <br /> No. Type Quantity WtJVol. <br /> _ -., V/' <br /> }; i�'( Y "'�.�R Y dY,$•.lt^^.�&'� Q1 �� `,r. � y� _a.c���y t A`� ..--'...«««... _ <br /> UJI <br /> C3 - <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> _._ <br /> ._ g 17q at7-- 1 <br /> _-_f � ..iN �. •j.'. t .a(,,. ...,�' t i �r $'S'v - f¢ 'SJ <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 condltion 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 confer to the terms of the attached EPAAcknowfedgment of Consent. <br /> I certify that the 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 /> Genera#or'slOftef s PnnledlTyped Name Sig nature <br /> 1 Month Day <br /> Year <br /> :.._r 16.International Shipments <br /> I.- ❑Import to U.S. ❑Export from U.S, <br /> ' m Port of entrylexit <br /> Transporter signature(for exports only); <br /> W 17.TransporterAcknewledgmenl of Receipt of Materials Date IeavingU.S.: <br /> 7 fr <br /> Transporter 1 PdntadlTyped Name <br /> O Signature f 3 Month Day Year <br /> Po <br /> Trp1 n fl-( <br /> rte- <br /> ,.;:u zs„ � ff d'� <br /> Q anspo ter 2'Printedffyed Iva .o <br /> M- <br /> a u $ <br /> s r Signature , <br /> Mpnlh Day Year <br /> 18.Discrepancy ` <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection <br /> ❑Full Rejection <br /> .� 18b.Alternate Faclity(pr Generator) - Manliest Reference Numbers" <br /> U.S.EPA ID Number <br /> , <br /> Faciiity's Phone: <br /> w 18c.Slgnature ofAlternato Facility(or Generator) <br /> Month (lay Year <br /> 19,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU 1 2, <br /> 3. 4. <br /> L20. nated Facility Owner or Operator:Certifiication of receipt of hazardous maledals covered by the manifest except as noted in Item 18aped Name <br /> Signature MV11onth Day <br /> Year <br /> }y # t "�. <br /> EPA Form 8700-22(Rev.3.05) Previous editions are obsolete: <br /> ' ... iltcCEf.�lh"r"�ra CB1/"rs s'v'v�rra rornrrrewq-,..-. <br />