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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 1.Generator 10 Number 2.Page 1 of3 Emergency Response Phone 4 Manifest Tracking Number <br /> WASTE MANIFEST r 1 S <br /> k.A ,�, „r 3.. 6 �" J J K <br /> 5.Generll is Name and MaIIlpg Addese Generefofa Site Address If different than malPn address <br /> ,�lt7;i',t3 I it,r.b ,,, !f( ?taf kt7P_' ' ( A ) <br /> 'i rot Cif,; 9Y <br /> ,r�i.47r rel 17 ' <br /> Generator's Phone: <br /> 6.Transporter i Company Name U.S EPA ID Number <br /> t1 o ..y' <br /> 7.Transporter Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S,EPA ID Number <br /> 'iAeit i"al. 1 hr37#ln::d ii. E,7 ', <br /> FaciliVs Phone: t!t.I xa!d /7fsit <br /> 9a, 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.NoI. <br /> 1 i3r,' 1 ' i^4,0 {"r 't)WO:' :'li:I I <br /> ! <br /> � 1 <br /> Lu <br /> Z 2. <br /> W <br /> U' <br /> 3. <br /> 4. <br /> I <br /> 14.Special Handling Instructions and Additional Information <br /> ..ft;i G , fat- : zr:r ;nJ til 11 , _ ,r !h'r.i7.' u ..t...=7.,,ml til <br /> 1 .^) tt ze+s- s;tiF 3u '4>3k isr'( <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 condition 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 EPAAcknowledgmenl of Consent. <br /> I cantly 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 generator)is two, <br /> Gener /O 'ntedR Leo Signature Month Day Year <br /> FJ- 16.IntematiQ al S merits 4:pr„- 1:1 mildit to U.S. ❑Export from U.S. Pod of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.TransporterAcknowledgment of Receipt of Materials <br /> Transporter 1 Printedffyped Name Signature Month Day Year <br /> p I . <br /> Za Transporter 2 Pdntedrfy"ped Name Signature Month Day Year <br /> K <br /> F <br /> I <br /> 18,Discrepancy <br /> 18a.Discrepancy indication Space 1-1Quantity ❑T e <br /> yp ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> l8b.Alternate Fadlity(or Generator) U.S.EPA ID Number <br /> Zi <br /> 1.1 <br /> LL Facility's Phone: '.. <br /> W like.Signature ofAilemate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> h19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) '.. <br /> G 1. 2. 3. 4. <br /> 20.Designated Faculty Owner or Operator:Codification of receipt of hazardous materials covered by the manifest except as noted In Ilam 18a <br /> Pdnted/ryped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />