|
Please print or type. I
<br /> Form Approved.OMB No,.2050-0039
<br /> UNIFORM HAZARDOUS 1.Generator i0 umbar r 7r a5 r 2.Page t of 3.Emergency Res oonse Phone 4,Man�i°faystTracking Numtier"�
<br /> WASTE MANIFEST T q ( fit,l?1t :i !• ). l-f�tJ ,rt 68 � rj�'rf 'v i $ L3
<br /> 5.Generaor's Ncur.o and Ma: Ig Address Generalors Site Address If(different than mailing address)
<br /> < t "r :`i'1` �l.E'"c}til ryr; ..,.t 7 „ t`
<br /> 7r,r 41 I��.ri ,IAr „
<br /> tR;t� 8 Pq T3TR+E-l'
<br /> Ge town, r s Phone;
<br /> 8,Transporter 1 Com anName U:S.EPA ID Number
<br /> T h fi0'.�IUX•,fii k;3
<br /> 7.Transporter 2 Company Name U.S.EPA ID Number
<br /> P p Y
<br /> 8.Designated Facility.Name and Site Address
<br /> (al�; tl'iC1 F�:[jjnri x`j() U.S.EPA toNumber
<br /> C OR 97015-89881
<br /> Facility's Phone;
<br /> ga, 9b.U.S.DOT Description(including Proper Shfpping Name,Hazard Class,to Number, 10.Containers 11.Total 12.Unit
<br /> HM and Packing Group(if any)) 13.Waste Codas
<br /> 1, No. f Type Quantity wuVoi.
<br /> tar 1'E SOt
<br /> ,iSr;.l}t,i1i f�Jt(i )�F" i�'..{� til FIL.Ti R ir'tf '
<br /> lU
<br /> Z 2.
<br /> C7
<br /> 3.
<br /> 4.
<br /> 14.Special Handling Instructions and Additional ntornalioli r r wr y
<br /> 'I SD 41 P
<br /> t 4Yh"" rrn .
<br /> �7•i ( t Ji') x, j i�' f7SY171'"w it' (St`I}^ moi ?11Ui'' t.".i + ..s3 ):ri?1a r� ' ( �'r, yator G''i.171�i+t 5 ,51 t lit. ia?1f11uY s
<br /> +r� �n^ ..,r :,, .w r•.. rr!r!r4. r;n!3i f y7t,-,jar+ }• t„tc »i _L+�.Y3P ': �•:,9r s} 7.,
<br /> 15. GENERATOR'S10FFEROR'S CE TIFICATIoN 1 he eby declare that the eontenis oft cdhel nment:oro.fullyand accurately described above by the propershlpp7ng name,and are classified,packaged,
<br /> marked and labeled/placarded,and are in all res ecisiln proper condition for transport accordlipg'tb applicable international and national governmental regulations.If export shipment f am the Primary
<br /> Exporter,I certify that the contents of this conslg Wren}conform to the(Dims of the attached#PAAcknowledgmant of Conpent,
<br /> I certify that the waste minimization statement id lilietl'in 40 CFR 282,27(a)(ithani a lar quentily generator)or(frr(tf I am a small quantity generator) true.
<br /> Goner l fferors Pdnted7typed Name Stgnahir Month Day Year
<br /> r iu, nternatan l if l
<br /> F- ❑Import to U.S. ❑Export from U.S. Port ofenlry exit:_F
<br /> ? Transporter signature(for exports only):
<br /> .Qateleaving U,S.:
<br /> w 17,Transporter Acknowledgment of Receipt ofMalariai , s .•”
<br /> Transpo gf T PnntedfTyped Name '
<br /> Signature
<br /> r r Signature Month Day Year
<br /> ,,y+• �` J .
<br /> (.. / i..r ... .. j'" ,. . '�''",• '; G `.W'lw•.G_,-'C `'"."r""""id.'"r,�."''" ....•-:'�' K' f tf f
<br /> Trenslwrter 2 Printed/ Signature Month Day Year
<br /> ed ame a..,
<br /> 18.Discrepancy ((��77
<br /> 18a.Discrepancy Indication Space Quantity t_hype
<br /> ❑Residue ❑Partici Rajaction ❑ ail Rejection
<br /> Manifest Reference Number:
<br /> fZ 18b.Alternate Facility(or Generator) U.S,EPA 1D Number
<br /> J
<br /> L Facility's Phone:
<br /> LOU 18a SignaturetureatAl(ernate Facility(or Generator)
<br /> d �TT7�Month Day Year
<br /> Z
<br /> � 19.Hazardous Waste Report Management Method'Codi s{i:o',,codes for hazardous waste treatment,disposal,.and recycling systems)
<br /> 1. 2.
<br /> 20.Designated Facility Owner or.Opefator.Codification f ree 1pt'ot hazardous.materials covered by(he manifest except as noted In Item 98a
<br /> Printed/Typed Name Signature onih Day Year
<br /> EPA Form 8700-22(Rev 12-17) Previous editions are obs�le(e.
<br /> -A"d s GENERATOR'S INITIAL COPY
<br />
|