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tPlease print or type. (Form designed for use on elite (12-pitch) typevmter.) Form Approved. OMB No. 2050-0039 <br /> UNIFORM HAZARDOUS 1. GenermorlD Number 2z Page 1of 3. Emergency Response Phone 4. Manifest Tracking Number <br /> WASTE MANIFEST rx- ; <br /> 4 � i1 <br /> 5. Generator Name and Mailing Address 1 Generators bite Address (ifdigeren(Ihanmal00 0 � ®�� <br /> 9 , <br /> ing address) <br /> T 9 a <br /> i - Get dA � <br /> Generators Pho e 4 <br /> 6. Tanspoder 1 Company Name LLS. EPA ID Number <br /> i W' nA riGi' Effi ` 4." Y�^= � ' 'aiti3sE'T C "�YixI�9 ' <br /> 7. T2nsporter 2 Company Name y Y U.S. EPA ID Number <br /> As k <br /> B. Detiignaled Facility <br /> mName and SileAddrass U.S. EPA IO Number <br /> aftwm ma <br /> ww, do MAIM W1 <br /> Fac�Tirys Phone: �"*r iedr--�1li al <br /> ga, 9b, U.S. DOTDesodpent (includng Proper Shipping Name, Hazard Gess, ID Number, 10. Containers 11: Total 12. Un8 <br /> HM and'Packing Grene fany)) 13. Waste Codes <br /> No. Type OuanBty WtNol. <br /> o � sks V 1 [ <br /> 44 <br /> z 2a <br /> ow <br /> 3. Mal <br /> ) <br /> I 4. <br /> i14. Special Handling Instructions andAddiAonal information 1 I <br /> a j <br /> 15. GENERATOR'SIOFFEROR'SCERTIFICATION: I herebydedare that Ne contents of this consignmentare fullyand.accurately described above by the proper shipping name, and are ciassified, packaged, <br /> marked and l2heled/plawmed, and are in all respects in proper condition for transport according to applicable intemationaland national governmental regulations. If export shipment and lam the Primary <br /> Exporter, I candy that the coptenls'of Us consignment conform to the terms of the attached EPAAcknoviledgment of Consent. I <br /> I beatify that the Mtn minimization statement identified in 40 CFR26P.27(a) Cel am a large quantify generator) or M) (ifI am a small quamitygenerator) is we. <br /> Genmkierd0frerors Pdnted/fyped Mergeti Signa(uiq Month Day r <br /> 16. InternationalShipments <br /> 1:1 Intend to U.S. ❑ <br /> Expodfmm U.S. Port of aving U.S.:T:' spodersignalure (for exports only): ' . Date leaving U.S. <br /> w IT TansporlerAdmoviledgmenl ofReceipLofMalerials <br /> �w Tansporter t Purd d/fyped Name <br /> pg r A Signature , <br /> /% 1 / r <br /> It <br /> Month Day Year <br /> gl ..s'rAOSif. 1`"�J <br /> Tina nspoderBPdnted/Typed Neme <br /> Signaturearc° c R Monty- Day Year <br /> Jr <br /> 18. Discrepancy <br /> 18a. Discrepancy indication Space El Quantity ❑Type <br /> ❑ Residue ❑ Partial Rejection ❑ Full Rejection 1 <br /> a <br /> MangestReference Number. <br /> h 18h.AItemAle Fadlity (arGeneator) - U.S. EPA ID Number <br /> Facility's Phone: <br /> w 18c. Signature of Alternate Facility (or Generator) Month Day Year <br /> Z I <br /> 05 19. Hazardous Waste Report Management Method Carlos (i.e., cedes for hazardous mete treatment, disposal, and recycling systems) i <br /> 3, 4, <br /> 28. Designated-Fadlity O% or or Opealoc Oedfiwem of receir ixt hazardous materials covered by the manifestexceptas neied N Item Ilia <br /> Prinled/fyped Name' . Stmalure <br /> L F i Mopnty L Dray Year <br /> EPA Form 8700-22 (Re 3-05) Previous edit are obsolete. - <br /> - � �' . DESIGNATED FACILITY. TO GENERATOR' <br /> i <br />