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tilt Please print or type. (Form designed for use on elite (12-pitch) typewriter.) Form Approved. OMB No, 2050-0039 <br /> UNIFORM HAZARDOUS 1. Generator ID Numbs ,,//J� 2. Pagelof :3p. Emergency Response <br /> ePPhone <br /> p� 4. Manifest Tracking Number g� <br /> WASTE MANIFEST' �,� lJ�07vyY9�.: O!/F!'�'2y, 93�'D . 012177785 �� f0 <br /> ' S. Generators Name and (Mailing <br /> .Address� Generatoes Site Address (ff different than mailing address) <br /> V / 7 rte✓ L <br /> Ge <br /> nerators Phone: <br /> 6. Transpode 1Company Nam - D.S, EPAIDNumber <br /> Aw/Z2 1W( x° <br /> 57 . A40* /,/V ;Wll1L &Fiwl4 lilal09RD®4926915Y ? <br /> 7. Transporter 2 Company Name U.S. EPA ID Number <br /> 8. Designated FacilityNameaan�rnnr'd,Site�Addddrreessss y— �yJ U.S. EPA ID Number. <br /> 3" 51 4040 �i„i E �*Qo <br /> ,phone: i ,,l " � �32,3� Ivo�2��9�� 611&117 . <br /> Facility's Phone: <br /> ga. 96. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Centelners 11. Tatal V. Unit 13. Waste Codes <br /> HM and Packing Group (if any)) <br /> No. Type Quantity Wt.Nol. <br /> o /, /�t,PC,Q� /f ,PtOPI/r!' //,��c3 S'D� f�®� � IYf (� M41” I <br /> � I <br /> Z 2. <br /> Do <br /> 3. <br /> 4. <br /> ,4. Special Handling Instructions and Additional Information <br /> --Y--"__ <br /> 9%P /�,QOrc� �9Co08�52 S�sc• > 2 /5/D o0lPe IOtV�/ <br /> 15, GENERATOWWOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above bylhe propershipping name, and are classilled,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 EPAAcknowledgment of Consent. <br /> I sanity that the waste minimization statement Identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (ifI am a small quantity generator) Is true. <br /> GeneratorslOffererinledlty dName Slgnalu� Q Month Day Year <br /> .r^CSat. / ® <br /> -� 16. International Shipments <br /> F ❑ Import fo U.S. ❑ ExportPrem U.S. Pon ofeniry/ext(: <br /> Z Transporter signature (for exports only): Date leaving U.S,: <br /> w 17. TranspoderAcknowiedgment of Receipt of Materials <br /> Tra rt Pdnted7ty, d /Name Signal - /nN y �� <br /> Year. <br /> 6 <br /> OOleC 64Ae & 7/� <br /> Z Transporter 2 Printed ped Name Signature Month Day Year <br /> F- <br /> 18. Discrepancy <br /> 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue <br /> ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number: <br /> 18b. Alternate Facility (or Generator) U.S. EPAID Number <br /> J <br /> U <br /> ra+. Facility's Phone: ' <br /> w life. Signature of Alternate Faefty (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 /> 2. 3. 4. <br /> 20. Designated Facllity0wner perator. Ceruncalionofmceiptofhazardo materials covered by the manifest except as noted in item ,ea <br /> Prinledityped Name Signature Mon Da Ye r <br /> EPA Form 8700-22 (Rev. 3-05) Prevlouse ' tonsareobsowte. DESIGNATED FACILIT ESTINATIONSTAT� (II fdIG9UIREeI <br />