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Ce. lk � <br /> Please print or type. (Form designed for use on elite (12-pitch) typewriter.) Form Approved. OMB No. 2050-0039 <br /> UNIFORM HAZARDOUS i G norator ID Number 2. Page 1 of 3. Emergency Response Phone <br /> 4 Manifest Tr k g Number (( - <br /> WASTE MANIFEST t e t o f r t I t P e,i I <br /> 5. G eatol' e and Mailing Address Generators Site Address (if different than mailing address) <br /> n e5 my _ te .. Ir v flbcit-1.�, <br /> CtAU 5 ', 70 <br /> Generators Phone: <br /> 6. Tran singer IC mpan � U.S. EPA ID Number <br /> I � ,- nt fsr ; . .` EFd c fk1Fi { u t ! t'f 07C tr JOJf. ` ^`} ( ,/T tif!'lr ( 7f-7 <br /> 7. Trapsl.p rtr2 CgmpanyN m US EPAIDNu bar <br /> li^``IeJ�r <br /> B. Desig ated,F ciity Nampand Site. cIf s U.S. EPA ID Number <br /> !< L _Lr <br /> f YL)1 }i} 1 ; 7 G DO in ` t <br /> ' '7r <br /> Giw I 1 . • f'i til 040217 <br /> Facility's Phone' <br /> ga 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, 10 Number, 10. Containers 11. Total 12. Unit <br /> and Packing fan 13. Waste Codes <br /> 9 Grou <br /> HM P G Y)) No. Type Quantity WLNoI. <br /> H0 -- <br /> N <br /> W <br /> Z 21Y ., it <br /> Tr <br /> ili _; 1 <br /> 4if <br /> 14. Special Handling Instructions and Additional Information <br /> tJ0 It fit [„ r Ge _ ter Y ) r f+ of I <br /> Irl . a; 5 <br /> ' i ,. 'rzTl_ . � .-, S ,� L � �. ? f`i2 � a - ai . , i DC;T , t / I SJ , <br /> .,, 1 4 <br /> 15. GENERATOR'SIOFFEROR'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 condifion 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 EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 261 (if l am a large quantity generator) or (b) (if l am a small quantity generator) is free. <br /> Generatorslofferoes PrintedlTyped Name Signature Month Day Year <br /> 16. Intemafional Shipments <br /> i— ❑ Import to U.S. ❑ Export from U.S. Pod of entrylexit: <br /> Z Transporter signature (for exports only): Date leaving U.S.: <br /> w 17. Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed7Typed Name - Signature - Month Day Year <br /> O <br /> a !r <br /> Z Transporter 2 Printed/Typed Name Signature Month Day Year <br /> NEEK <br /> 18. Discrepancy <br /> 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ ResiduePartial Rejection ❑ Full Rejection <br /> ❑ <br /> Manifest Reference Number: <br /> F 18b. Alternate Facility (or Generator) U.S. EPA ID Number <br /> J <br /> U <br /> Facility's Phone: <br /> w 18c. Signature of Alternate Facility (or Generator) Month Day Year <br /> Q <br /> Z <br /> 0 <br /> 19, Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> 1 . 2. 3. 4. <br /> 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Hanson typed Name Signature Month Day Year { <br /> I <br /> EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />