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T T I I I I 1 0 O 0 <br /> II-1 OOOOOOM -4O <br /> v j 1 -_ N — <br /> 7 � � � Q0 0 O v <br /> W W W W W O o Q N Ill <br /> A -P�lU) C7) WO O <br /> NN 00000 — *k � 0 <br /> O v W 0000Wa � CO � <br /> Q000UT0) OC (CD <br /> O -n TI TI TI TI v <br /> r r r r r Z <br /> mmmmmo z* <br /> _m :E W <br /> 0 � i1oo105 co <br /> Please print or type_ 00 � � � O 3 � <br /> Mt3 No.2058-88". O O^ N N <br /> UNIFORMForm Approve?0 � W <br /> MANIFEST 7.Generator 10 Number 2.Page lof 7.Emergency Response Phone 4MmNnett 7rackr^C�,�Number �"��"� N <br /> WASTE MANIFEST - 012663080 FL ^ ^ <br /> S�-ieralor'S Name and Mailing Address (Jl UI G) G) '" En m <br /> Generalor'sSlle Addre65(d d�lferenl loan rc.d.lnp oddre-<_. � � VI V! V � <br /> W � v v W � v <br /> Generator's Pnpne_ W W <br /> d.Transporter t Campany Name U.S.EPA 014-t- 07W <br /> 7,Transpoder2Company Name <br /> V S EPA IC NumM� U) W <br /> S.Designated Facility Name and Site Address U.5 EPA ie td.�nmo 0 <br /> O O <br /> O 7 <br /> FaClllry's Phone'. <br /> 9a 9b.U.S.DOTOesorlptlon ,,Ir Jag Proper5nipping Name,Hazard Class,ID Number. 10_Containers tt T-, 1 Unn D <br /> HM and Packing Gmup illanv:� No. Type Quanta, Wt Vol t3 Waste Codes <br /> (D <br /> O Q <br /> __— O <br /> i =3 <br /> w L <br /> U _ <br /> a � <br /> I � <br /> 4. CD <br /> O <br /> F <br /> 14 Special Handling Instructions and Additional lnformatiort O <br /> �C <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATIDN:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are printed,packaged. < <br /> marked and Iabeledlplacarded,and are in all respects in proper coni for transport according to applicable international and national governmental regulations.If export shipment and t am the Primary S <br /> Exporter,I ceNy that the contents of[his consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> !certify Inas the waste minimization statement identified In 40 CFR 282.27ia)(if I am a large quantity generator)or(b)(If am a small quantity generator)is true. <br /> Conerators'Offeror's PrintedlTyped Name Signalpre Month Day Year rCn <br /> j 16 International Shipments " <br /> 2 11 import to U S, ❑E4pon from U.S. Pod of entryie*it <br /> Transporter,signature(for eepods only): <br /> '. <br /> rr tz TransponerAcNnowtedgmenl of Receipt of Materiels Date heaving U.S. <br /> W <br /> Transponer 1 Pnni Typed Name <br /> O Signature Month Day Year <br /> 13- <br /> '2 Q Transporter 2 PrinletllTyped Name <br /> C Signature Month Day Year <br /> 18-Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑Quantity ❑Type ❑Residue <br /> ❑Partial Rejection ❑Full Rejection <br /> 186.Artemate Facility(or Generator) Manifest Reference Number: <br /> U.S.EPAID Number <br /> U <br /> LL Fscditv's Phane: <br /> t8c-Signature ol'Aflernate Fandity(or Genemloq <br /> W <br /> a <br /> z Month Day Yaar <br /> w19.rfazardi Wase Report Management Method Codes fie..codes(or hazardous waste treatment,disposal,and recycling syslemsJ <br /> o 2. 3. <br /> C CD <br /> 4 n <br /> 1 <br /> 20 OeSignated Facility Owner or Operators Certifrration of receipt of hazardous materials covered by the manifest except as noted in Ilam 1ga C n <br /> Pnntc Typed Name <br /> Signature D O <br /> Month ay Yeas Q <br /> EPA Form 8780.22(Rev 12-17)PreviG s editions are obsolete _ <br /> GENERATOR'S INITIAL COPY <br /> D N <br /> CD <br /> O <br /> 0) Cn <br /> W <br /> O fn v <br /> (D W <br /> N W <br /> W LrI <br />