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A6sb print or type,(Form designed for use on elite(12-pitch)typewriter.)
<br /> 1.f,1enerator ID Number Farm Approved,OMB No,2050-00 1,)
<br /> UNIFORM HAZARDOUS r 21—
<br /> e t of 3,Er ergeney Response Phorse 4.Manifest Tracking Number
<br /> WASTE MANIFEST , t) ¢�.• z ar.
<br /> 5,Generator's Name and Mailin� ddre � t � �� �� i � ����y � � � � �br
<br /> . . G B F
<br /> Go* Ices SI Address(if different than mailing address)
<br /> ESQ OGyD Or
<br /> Generator's Phone:
<br /> fi,Transporter 1 Company Name
<br /> :� U.S.EP lD Number
<br /> � �:, s F 4, t" K tit l� � C.. - r'K� r,1 F
<br /> 7,Transporter 2 Company Name a S(r L " 7r a i Oi ' ' 0<4"
<br /> U.S.EPA ID Number
<br /> A Designated Facllity Name and Site Address
<br /> U,3,EPA It Number
<br /> �� a �. G..r ,.k d�'r.�cam• i,.� �"�r �„3t°� 3
<br /> Faal tftf ys hone:
<br /> ga, 9b U.S,DOT Description(Including Proper Shipping Name,Hazard Class,ID Number,
<br /> HM and Packing Group(if any)) 10.Containers 11.Tota! 12.Unit
<br /> 13.Waste Codes
<br /> No, Type I" T'
<br /> wt.Ngl.
<br /> 1` x"0A a'rdl� ss1� a. ,a�rz � dcat
<br /> F
<br /> Z Z
<br /> LLIA
<br /> 4.
<br /> 14.Special€candling Instructions andAdd@fonai Information
<br /> z , L �-.�
<br /> 15 GENERAFOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of[his consignment are fully and accurately described above by the proper shipping name,and are classif ed,packaged, ; r
<br /> marked and labeled/placarded,and are in all respects In proper condition for transport according to applicable intemalienaland natlonai governmental regulations.If export shipment and I am[he Primary
<br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAdnowledgment ofConsent.
<br /> I certify that the waste minimization statement Identified In 40 CFR 282.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)Js true.
<br /> Generafor'slOfferoes Printedfryped Name Slgnafure
<br /> may ' Month Days ar
<br /> i6.Inlernalional Shipmentsof e
<br /> ' �" ��� '""'t. �af• `���M �
<br /> ❑impar!to U.S, ❑Export from U,S,,, Pert nlry/exit:
<br /> � — 7ransportarsignalura,(icrexporisoniy};
<br /> '17.TranspnrlerAcknowfedgmant of Receipt of Materials Date leaving U.S.:
<br /> 4 Transpcdgr 1 PrintedlTypad Name
<br /> 5ignaturaw.°•
<br /> a .. - }' ,LDay Year
<br /> J Manch
<br /> Transporter 2 PrintedfTyped ama {
<br /> re
<br /> Signature
<br /> r- ".I Month Day Year
<br /> rI
<br /> 18,Discrepancy `"" •
<br /> 18a.DIscrepancy lndlcallan Space
<br /> ❑ 0uantify ❑Ty"' OResfdue
<br /> ❑Partial Rejection El Full Rejection,,
<br /> 18b.Alternate Faculty(or Genemtnr) MaNfesl Reference Number:
<br /> =� U.S,EPA lD Number
<br /> C>
<br /> ua- iFacjlitys Phone:
<br /> F19Ha;zra'o;u;.,
<br /> f Alternate FacilEty[or Generator)
<br /> 2 Month Day Yea
<br /> r„,c4
<br /> Hazardousaste Report Management Method Codes(!,e„codes for hazardous waste treatment,disposal,and recycling sys(ems)
<br /> „ . 4,
<br /> 20.Designated Facllfty Owner or Operator:Cer811cation of racelpi of hazardous materials covered by tate manifest except as Rated in Item 18a„
<br /> PnntedrTyped Name 1
<br /> r' Signature
<br /> Mopth D y Year
<br /> •S.. �'`("„'.�� �”' �. /may l �
<br /> EPA Form 8700 22(Rev,3.05) Previous editions are obsolete,
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