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Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 14.Manifest Tracking Number <br /> WASTE MANIFEST <br /> 0r ' <br /> :23` JJ K <br /> _ <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> e�j j nor; %tri t J;' rr 1 3 :_:.t t sr;FifSf <br /> 511M-4 <br /> Generators Phone 3:�� t vs y <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> i`;:ljK'.�f••" �?4�'i''•.'':JI,)t:°a��"•;6�`;1.,t'iL,.r�',i14..t.'.:W ISP$,:. ,:'<.;J+..',;i+>�."s1•��yr:' <br /> 7.Transporter 2 Company Name U,S,EPA ID Number <br /> 8.Designated Facility Name and Site Address__ ,( gry U.S.EPA ID Number <br /> Facility's Phone: <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) <br /> No. Type Quantity WI.IVoI.. <br /> 1- ii3r 7i.i r. riA Ca �.t�D�l . w.T? _F Vi try (?^.Tit,-, ' •"ut t . <br /> X "-' P :fia <br /> O E <br /> (C) 3 <br /> !v <br /> Z 2. <br /> W <br /> C7 <br /> 3, <br /> 4. <br /> 14.Special Handling Instructions and Additional Information t <br /> 3rd 1jt'� [fILE E,RG#471 xi�'.5'? r`-q G•s clrt It ' <br /> E.�_ 1:�OsTt�?�fCJ�. s:..:;��C,���'' ~�i�•vti�t�fr,<Mi�:§::-t:;',€� � <br /> I-',1-'1Pj itrf=R'3 SHOUILD VE TR.':0,1E SMD <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 contliGon 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 EPAAcknowiedgment 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(b),(ifljam a small quantity generator)is true. <br /> Generalors/Offeroes Printed7yped Name Signature Month Day Year <br /> 16.International Shipments 1:1 Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.TransporterAcknoWedgment of Receipt of Materials <br /> ►- Transporter 1 Printed/Typed N' e <br /> Signature for y r `} I g , Month Day Year <br /> N ,ri i e �.' ( 1i'•"l f f t% r' _ .,rr.' f J':J� t.•-••'Mx.¢...... �� ..r i. <br /> Z Transportef 2•Priro6d/Typed Name Signature.r'` Month Day Year <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity 1:1 Type ❑Residue ❑Partial Rejection <br /> Dull Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> ZIV <br /> Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> C3 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 /> PrintedrTyped Name Signature Month Day Year <br /> EPA Form 8700-22(Re 12-17) Previous editions are obsolete. DESIGNATED FACILITY COPY. <br /> IF YOU RECEIVED THIS MANIFEST,YOU HAVE RESPONSIBILITIES UNDER THE e-MANIFEST ACT.SEE INSTRUCTIONS ON REVERSE SIDE. <br />