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Pleaseprint or type.(Form designed for use on elite(12 pitch)typewriter.) Form Approved.OMB No.20500039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2 Page i of 3 Emergency Response Phone 4 Manifest Tracking Number C i <br /> WASTE MANIFEST ;A I r 0 f,±;€' t 7 3r +< 1 ,t r� ;ri �,.,ri1Y .� ; i ;-r x 1;-s. WaJ <br /> 5.Generators Name and Mailing Address -Getlmaloes Site Address(if different than mailing address) <br /> Generators Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> `I, <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> I I i:,I vl II <br /> li ,A l§E7 If <br /> Facilty'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)) No. Type Quantity Wt.Nol. <br /> Ift <br /> 0 <br /> O d <br /> W 2 -. <br /> 3. <br /> 4. <br /> i <br /> 14.Special Handling Instructions and Additional Information <br /> €e � ...tD%lt ,r ,,.4tE C° 4_n)d..: [ i;'.'i'Sf ..._ . r ...r.,o1i Iz4Jl,"( 4J(l`; .4ra;.f." <br /> r <br /> 1P .i'Tf n .... <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 ciassiied,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 l 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 262.27(a)(if l am a large quantity generator)or(b)(if I am a small quantity generator)is We. <br /> GgnetatorslOHerors Printed typed Name ,Signpture ' Month Day Year <br /> —i 16.International Shipments <br /> F— ❑import to U.S. ❑Expodfrom U.S. Pod of entrylexft. <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> Liu 17 Transporter Acknowledgment of Receipt of Materials <br /> 'ranspor(er)8nntedll'yped Name d / I f Signature j," �, it E Month Day Year <br /> a f tt 1 ' y, <br /> if <br /> .z Transporter Printesirryped Name,* r <br /> l a <br /> Signature - �`,. Month .Day Year <br /> If if <br /> f 4 <br /> - T18.Discrepancy 1 <br /> 18a Discrepancy Indication Space ❑ Quantity ❑Type - ❑Residue J ❑Full Re' <br /> ❑Partial Rejection lection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) US,EPA ID Number <br /> Zi <br /> V <br /> W Facility's Phone: <br /> W 18c.Signature ofAltemate 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 /> 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 iso <br /> Pnntedliyped Name ; Signature f v( Mon!h Day Year, <br /> ,: r'I', , t � � V I <br /> `l. ' IsJI ( It 1 1�_ I4 <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. "' 1r�ti } . D�AM NAED FACILITY TO GENIEiNTOR <br />