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Vi <br />' or type. (Form designed for 'ter.) <br />use on elite (12 -pit <br />UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />1. G eoa(or 10 Number <br />f ,Z ! <br />Paga i of 3. Emergency Response Phone Form Approved. OMB N0.2VM39 <br />4• Manlfost Trlicking Number <br />Q <br />Nam 5. Generator's Naand tJj[irg l! 6}1 <br />`W�� Site Address iling <br />(if different than maaddress) <br />FV <br />Gaderates �"' ' �53 714� <br />Phone: �i <br />6. Transporter 1 Company Name <br />(� - <br />T c. ce-S <br />ta pa er 2 CCompaompa <br />7. Tny Name <br />U.S. EPA tD Number <br />7 <br />'�`ld ` <br />8-D esignated Fsality Name a e end S(teAddress <br />U.S. EPA 10 Number <br />D 9g� y/! 993 <br />•�•{ �fi�+Cs`! <br />U.S. EPA 10 Number <br />Fa Vs Phone: /41b <br />ga, 9b. U.S. DOT Oescdptton (Including ing Proper Shipping Nam, Hazard Class, 10 Number, <br />Him and Packing Group (if any)) 110. Containers <br />11. Total 12. Unit <br />1`1g /A,� � Type <br />4uantity WtNot. 13. Waste Codes <br />1.7 <br />f— <br />.., 15. GENERATOWSlOt•FEROR'S CERTtFtCAT10N: 1 hereby declare Oral ffm contents of this consignment are fully and accurately descdfred above the �i S marked porter not lrg e M /t the onceded, and are In an respects in prollconMen for transport according to applicable International and national prober ahfpping name. and are classified, padtaged, <br />Exporter t codify that the contents of this t»nslgnmrent corrtomt the terms of the attached EPAAduwwladgment at Consent Snnmental regulations it expect shipment and 1 am the Prfmary <br />I certify OratMe waste mtdmizall'statement id -Wed kr 40 CFR 26227(a) (If 1 am a large quantfly generator) or@) Qf t am a smaO uan6 <br />Genemtor'aloff Printed/f Name q tygenerator) true <br />Signature <br />`s� Mon),Y <br />—r 16. IntemaOocrel Shipments <br />I— Import to U.S. ❑Export from U.S. Porto !exit <br />= Transporter signature (for exports only}: <br />WW 17. TransporterAdmowledgment of Receipt of Materials Date laying U.S.: <br />Tmnspportr1 PPdntUsdName rgnat� <br />co e'mseo <br />� j r/ MonOt Day Yea <br />Q Transporter 2 d Name <br />Signature <br />/ <br />MOA Day Yea <br />i8. Disdxepancy 12 112r !� <br />18a.0rsd7epatt�Y 3p ❑ Quangty ❑T <br />❑ ResWue ❑ panda! Rejection 19F.11114seft <br />o , <br />ill <br />f40 b v = Manifest Reference Number i86.A amara FacTty (or nerator) [fes 6 <br />®�u , U.S. EPA ID Number <br />tAT 99-021 <br />Fac�tys Phone:{.' A r 1 fr vtTD 9 1` } <br />w 18c S(gnalure od/Otemate Facil (or Generator) <br />z Month Day Year <br />w19. Hazardous Waste Report Management Method Codes (Le, codes for hazardous waste treatment, disposal, and recycling systems) <br />LU R2 i' 2 3. <br />4. <br />20. Des gnaledTFdIl Operator. Cedificafion of receipt of s materials covered by the ma:]anifest except as noted kr Item 18aPrirdedUiypad Signa <br />_ IT <br />�Pr <br />PA Form 8700-22 (Rev. 3 0� Previous editions are obsolete. <br />SIGNATED FACILITY TO DESTINATION STATE (IF REQUIRE' <br />