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Please printortype.(Form designed for use on elite(12-pitch . ewritec) form Approved.OMB No:2050-0039 <br /> rator ID Number be <br /> UNIFORM HAZARDOUS 2.Page 1 of 3.Emergency Response Phone 4.Manifest Trackin 'Number <br /> WASTE MANIFESVIv ;'1"i' 44 15" <br /> , JJ <br /> 5.Generator's Name and Mailing Ad�d�Yress Generatne-Site Address(if different than mailing address) <br /> alis 11 yk•roi..�3`i! F�,$JJ., iN0 ) 77 <br /> f <br /> rf -'ti <br /> ..r r 4 <br /> .� GeneratAflt <br /> �one: � f1�a;?h�? ;1'3 .�A °I .ry,J{`a <br /> 6.Transporter l Company Name - •,e. ° ` ... U.S.EPA ID Number <br /> 7.Transpoiter"2 C'rnpahy Name IT U.S.EPA 1D'Number'' <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> '.:#f•r�1E?�`lja��('(� rl�l.Jr%°t�Je� If fl�!'d.4,9,. <br /> }t;ts AiJvjg' Nf)t01 <br /> 41 Facilitysphorer'.ra!'t'rfLs`;r P+3`i/ <br /> ga• 9b.U.S.DOT Descrip6oimdui)ing Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total <br /> HM and Packing Group(if any)) No. Type Quantity 12 12..Unit 13•Waste Codes <br /> 1. <br /> Q Ix f'A S�,f�.}t.tt1 FK i 1'. t.5 I t }[ a.t jA R-f- 0 11-41ir'� Y ��..b�,,.y .-. L/05, <br /> QI 1•.I_. �.ir 11t �7 {% - V/\ \�•n" <br /> Z 2. t= a <br /> LU <br /> 3. : <br /> '� �� l��®9vc7� .S i G-� S• <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 15. GENERATOR'S/OFFEROR'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 EPAAcknowledgment 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( (rfI small qugrptify gerner�tor)is triie. <br /> Generator s/Offer s PrintedlTyped Name' j Signglyre I ! f i � 1� Month Day Year <br /> 1 ' fl � n1' '1yf.g 4 3} <br /> F— 16.international Shipments Z I <br /> Z ❑Import to U.S. ❑Export from U.S. Port of entry/exit: .P <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> n= 17.Transporter Acknowledgment of Receipt of Materials r' <br /> Transporter 1 Pdnted/Typed Name <br /> r .._ `. Signature %nth. Day Year <br /> CL <br /> (/� k' ` i f t•°" "r �� °S,.r•' C .1y f „r7 e �S f R k <br /> Transporter 2 PrintAM ype Name Signature Month Day r Year <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑PartiabReJectlon ❑Full Rejection <br /> 18b.Alternate Facility(or Generator) Reference Number:tor) U.S.EPA ID Number <br /> J <br /> Facility's Phone: <br /> W18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> 4 <br /> Z <br /> 05 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1 2. 3 <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name 4j Signature 4 Month Day Year <br /> EPA Form 8700- (Rev.3-05) Previous editions areobsolete. s <br /> r' ;;` DESIGNATED FACILITY TO GENERATOR <br />