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jForm degigned for ttse on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-003'9 <br /> UNIFORM�HAZARDOUS '1, <br /> Generator ID Number ', '2:Page 1'of 3 Emergency Response Phone. 4.Manji est Trackin Number C <br /> WASTE MANIFEST t-? `iC£�t3 t:>i}1 �� 4. �3t3� 904 r�918a �!10 1 'FLG <br /> 5..Generator s Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> 01, <br /> Generator's Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> TfiTTa �YF2 UAt 0,' t', f+" fJ!4AI 'Eti'+F T141" . F',111 ifiklr�f2"`i'C` <br /> .7.Transporter Company Name U.S.EPA ID Number, <br /> 8 Designated Facility Name and Site Address U:S'EPA ID Number <br /> `f' 95, 11 W.LIUS ;aor,Y.s Off' »Tri <br /> 13 VVY, 14'117 89001 <br /> Facility's Phone: 3 t kA <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. J Type Quantity Wt.Nol. <br /> ac 1 <br /> 91432-64, Waste Corrosive 11quid, adldicx, T�Otl:� 791 <br /> X tY.o,s . (eu� tsx ia� ilo�phoriv.ac�i d);f t3, <br /> z.,tJ i�RaO, Waste Aerosols, [ lass ua ilL { i, riot 33 l <br /> 11 1 <br /> , <br /> AS <br /> 4. y _ <br /> F' <br /> 14:SPecial Handling Instructions and Additional Information <br /> S) tp k(lted iA 3)i fi-O'7U11•:'1'71:08-E335�it " f, 154 2) pdJi'it,7J.ub4e acsro*63.8tfappidl, 0236t1315 <br /> 126lo <br /> 1 . GENERATOR'S/OFPERO -CERTIFICATION!:l.hereby declare that the contents of this consignment are ful(y'and accurately described above by the proper shipping:name;and are classified,packaged ' <br /> marked arid lR'Sabeled/placarded,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 of Consent. <br /> I certify that the'waste minimization statement identified in4b-CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generators/Offerors Printed ypeV Name bignatur Month ay ear <br /> 16.Intemational Shipments <br /> 0 Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter signature far exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Pdntedfryped Name g MI) Dayear <br /> CL <br /> _.., <br /> aTransporter 2 Printedfryped Name ignature MonthDay Year <br /> a T <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space El QuantityElT e <br /> Type El Residue El Partial Rejection Full Rejection <br /> Manifest Reference Number: <br /> ,18b.Altemate Facility(or Generator) U.S.EPA ID Number <br /> �..Facilitys Phone: - <br /> w. 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Z <br /> 19 Hazardous Waste Repoit Manayamont Method Codes(i.e.,codes for hazardous waste treatment,disposal and recycling systems) <br /> 20.Designated Facility Owner or Operator:Certificati of receipt of hazardous_materials covered by the manifest except as noted in Item 18a <br /> Printed/Ty pe a Signa ur Month Day Year <br /> EPA Form 8700-22•(Rev.3-05) Previods edition are obsolete. DESIGNAT50 FACILITY TO GENERATOR <br />