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PIpASe print or type. (Form designed for use on elite (12-wo rypd)iRiger.) <br />I Ftum Annmved (SMR Nn 205f1.(NIS9 <br />UNIFORM HAZARDOUS 1 ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Nraaber <br />WASTE MANIFEST Q Q U r ;o - 447- - ; VVI 0 0 2 9 9 9 G B F <br />5. Generates and Ad / Generabes Site Address (N differed than mailing address) , <br />V, Z', Jo J/ v e l"'0' <br />//X e, f/, r <br />Ge s Phone: l <br />6. T 1 Company Name U.S. EPA ID Number <br />® I cid II �` <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. D Facility Name a She Address U.S. EPA ID Number <br />�f * d!! x if <br />s0 60 <br />ty: <br />9a. 9k. U.S. DOT Description Oxk d M Proper Shipping Name, Hazard Class, ID Number, 10. Contairnes 11. Total 12. Unit 13. Waste Cafes <br />HM and Packing Group (d any)) t l No. Type Quantity WtJYoI. <br />� <br />z 2. <br />W <br />3. <br />I L <br />4: <br />14. endAddlsml <br />rl <br />["i <br />9 <br />I& CE by consignment are kitty and acaeaiely desctbed above by the proper slipping name, and are classified, packaged, <br />. f here declare that the contents of this can ' <br />narl®d and �. and are in in proper condition for transport according to applicable aktemaionaland national governmental regular* . ff expest shipment and I am the Primary <br />EVOdw., I certify that the contents of ' consignment conform to the terms of the attached EPAAd wMedgment of Consent. <br />I � 9ral the wee minimizes ' statement identified in 40 CFR 262.27(a) (d I am a large quelbly genaraW) or (b) (I I am a sinal quoit gereraler) is cue. <br />�,�r Name Signature Month Day Year <br />/ t k G1FCfr, A TCrtM1AA1tw <br />J 16. international Shipments <br />Z ❑ Import to, U.S. ❑ 6cport from U.S. Pak of entiykexit <br />— Transporter sig A- (for exports only): Dale batt U.S.: <br />17. TtansporierAdmowledgrnent of Receipt of Materials <br />Transpoder t yped Name Signature nkat Year <br />aoct <br />Q Transporter R Moana _D" <br />r� <br />war <br />t - <br />Ito low0a <br />?8. Discrepancy <br />18a. Disaepakcy krdication Space ❑ Partial Ft*di n ❑Ful Rejerkan <br />❑ Quantity, ❑Type Residue <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />_J <br />V <br />LL <br />Facility's Phone: <br />W 18c. Sgnalure of AHemate Facility (or Generator) Month Day Year <br />Q <br />z <br />H 19. Hazardous Waste Report Management McOrod Codes (i.e., codes for hazardous waste treatment, disposal, and recydirg system) <br />C 1. 2 3. 4. <br />20. Designated Facility Owner or Operates: Certiliccation of rept of hazardous materials covered by the manifest except as noted In Nem 18s <br />PrintedT Name /� % <br />Signature <br />g r <br />'41, <br />EPA Form (3700-22 (Rev. 3-05) Previous editions are obsolete.' <br />DESIGNATED FACIi 1TY TO GENERATOR <br />x� <br />N'. i�a 1 <br />'41, <br />EPA Form (3700-22 (Rev. 3-05) Previous editions are obsolete.' <br />DESIGNATED FACIi 1TY TO GENERATOR <br />x� <br />N'. i�a 1 <br />