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Please print or type.(Form designed for use on elite(12-pitch) pewrilEar.) Form Approved.0MS No.2050-0039
<br /> UNIFORM HAZARDOUS 1.Generator ID Number 2,Page I ofLIN
<br /> Emergency Response Phone 4.Manifest Traclring Nunftr
<br /> WASTE MANIFEST ►1S_f`;,:;Si: r':t J. 1`a'�f�;6tF 008548600 FLE
<br /> 5.Generators Name and Mailing Address Generators ae dress different than mailing address)
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<br /> 1 i'T'"T'i'i i.i.1ii'='.' )'.irks �4.k1 t.r +,P`.T i+; i.liFi;trryi I ?NiJ T 1
<br /> Generators Phone' . . 1 I,;7
<br /> 6.Transporter 1 Company Name iS_EPA ll Number
<br /> St"R r i.=W`-!.,'r :ill _ 'r] 'i W u 4' ,in- 1.1ir I I.;1;t-c"I"I"ilpc,-)a
<br /> 7 Transporter-1 Company Name U.S.EPA ID Number
<br /> 8.Designated Facility Name and Site Address i1 ,ti�r `� t }-� U.S.EPA ID Number
<br /> 9:-4..17417
<br /> Faci%?sPhone:
<br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11 Total 12.Unit
<br /> HM and Packing Group(if any)) No. Type Quantity Wi.lVaf. 13.Waste Codes
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<br /> ISS+GI1"OD:Li }]r_'t'l3?18[!41� ::. �- '�It'• •!.�. �i".t'-=t f .fr.
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<br /> 14.Special Handling instructions and Additional Information
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<br /> ..`(''r.,:?,`.'Yt�1;Lalt�i"<: �-- C;rl .i! -• 1_�Q�Ga17;rC;�t� . , l.ft':)t:�; 1 �'at`.""�f.•�i7 ( )'.';1:7.:i fl .�-.'r:'_ {�:�: ��17 t�'1
<br /> 15. GENERATOR'SJOFTEROWS CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper slipping name,and are classified,packaged,
<br /> marked and labeledfplacarded,and are in all respects in proper condition for transport according to applicable intemational 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 EPA Acknowledgment at 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)(if I am a small ggantity generator)is true.
<br /> Generators)Uneror's Pdntedlyped ameg71-1
<br /> 4/ M" ay Year
<br /> '.',h 1� 1."P � I .,:n✓' A 1 I I I :r.
<br /> 16.Inlemabonaf Shipments
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<br /> El to U.S. ❑Export from U.Sjj J Port at.144
<br /> ? Transporter signature(for exports only): ! Date leavilayfS..
<br /> W 17.Transporter Acknowledgment of Receiptof Materials
<br /> Transporter 1 Printed[Typed Name Signature Month Day Year
<br /> a {�k ?ra f r:lY •,,{ cL^ c 1,{ I'ry
<br /> 4 Transporter 2 PrintedrTyped Name 5 ro Month Day Year
<br /> X I I 1
<br /> 18.Discrepancy
<br /> 16a,Discrepancy Indication Space ❑ Ouaniity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection
<br /> Manifest Reference Number.
<br /> 16b.Alternate Facility(or Generator) U.S.EPA ID Number
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<br /> Faclity's Phone:
<br /> LU lat-Signature of Alternate Facility(or Generator) Month Day Year
<br /> z I I I
<br /> 19 Hazardous waste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recyciirp systems)
<br /> Ul 1. 2. 3. 4.
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<br /> 20.Designated Facility Owner or operator.Cerlifiration of receipt of Illlazardous materials covered by the manifest except as noted in Item 18a
<br /> PrintedRyped Name , Signature Morm Day Year
<br /> EPAForm 8700-22(Rev.3-05) Previous editions are obsolete. r;!{,- r,;•i Q �,;rs,7n r ^U I,-;Jj
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