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Please print or type. (Form designed for use on elite (12-pitch) typewriter.) Form Approved, OMB o. 20 0-0039 <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2. Page 1 of 3 Emergency Resp e Ph 4 M rfest Tracking Number <br /> WASTE MANIFEST air;=' s 4 .£ :sy u ei r k� a '� .. .,"fir rF f � fmr �h I l% } �_.kl JJ <br /> S. Generators Name and Mailing AddresIGenerators Ste Address (ff different than mailing address) <br /> Generators Phone. r , ', c f..11. 7 °� a of E ., f uX✓:'. ! <br /> 6. Transporter 1 Company Name U.S. EPA ID Number <br /> r$ Al <br /> C. . <br /> r J <br /> 7. Tran`spoder2 Company Name "" U.S.EPA ID Number <br /> 1118 <br /> Facility Name and Site Address U.S. EPA ID Number <br /> F.+F r <br /> f >' >< • - u� ,, .. -.E �. '�'`t°' ' `c <br /> Facility's Phone . `; <br /> 9a. III U.S. DOT Descripfion (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Total 12, Unit 13. Waste Codes <br /> HM and Packing Group (if any)) No. Type Quantity Wt.N01. <br /> 1 d 'A ra ` ` f .0 r 7 <br /> o R s d _I <br /> n r , • .i d e ' 1 k�o , 41p fl ';SiIUD <br /> • r 6 <br /> 3 <br /> 4. <br /> 14. Special Handling Instructions and Additional Inf0mrafion <br /> 4y A' # (vb c x %Y .t' ',.. <br /> 44 <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 labeledlplacarded, and are In all respects in proper condition for transport according to applicable international and national governmental regulations. If expel shipment and l am the Primary <br /> Exporter, I codify that the contents of this consignment conform to the terms of the attached EPAAcknowledgmenl of Consent /'r (^ <br /> I certify that the waste minimization statement Identified In 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity gepI is true. <br /> Generatorsppl0ffero11rs PrinledlType[dd Nam Signature f �' Month - Day Year <br /> fJ ,n4-t 7xr 1 n. . P .i�et° { . . y.r .t,.:- ` r.l <br /> 16. ImeJnatibmal SHipments3 e <br /> z �' ❑ import to U.S. a ❑ Export from O.S. �- : Pod ofenlrylexit: <br /> Transporter signature (for experts only): Date leaving U.S.: <br /> w 17. TranspoderAcknowledgmenf of Receipt of Materials <br /> Traospoder i PrinledfTyped Name •q Signature : - Month Day Year <br /> °. 6 J II If (4FS., esr-mv t>> ..�^ s "4, <br /> Z Transporter Prinled(ryped Name d" " '" SapatrGe t r, � Month Day War <br /> � { p <br /> 18. Discrepancy <br /> 18a. Discrepancy Indication Space ❑ Quantity ❑Type ❑ Residue ❑ Partial Rejection <br /> ❑ Full Rejection <br /> Manifest Reference Number: <br /> 18b. Alternate Facility (or Generator) U.S. EPA ID Number <br /> J <br /> U - <br /> LL Facifity's Phone: " <br /> w 18c. Signature of Alternate Facility (or Generator) Month Day Year <br /> Q <br /> Z <br /> N19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> 1 . 2. 3. 4. <br /> I <br /> 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials severed by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature Mon(h Day Year <br /> EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GSENERAYOl INITIAL COPY <br />