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Piouse print or type,(Form designed for use o I.elite(12•plich)typewriter.) <br /> t Generator I Number � Form Approved.OMB No,2050.0039 <br /> UNIFORM MA7ARDOUS 2.Page 1 of 3.Emorgenny Response Phone 4.Maillfest Trac ing Number <br /> t C <br /> WASTE MANIFEST t:_.< :. ) '4 � FL E <br /> 5.Generator's Name and Maii(ng Address Generator's SHe Address(if dilforent4han mailing address) <br /> Generator's Phone. <br /> 6. ransporter ompeny Name <br /> U"S,EPA ID Number <br /> 7.Transporter 2 Company Name <br /> U:S,EPA ID Number <br /> ------------- <br /> 8.Designated Facility Name and SiteAddress <br /> I U S.EPA ID Number <br /> 0;k .. <br /> Facility's Phone: <br /> ga, W U.S.DOT Description(including Propi ir'Shipping Name,Hazard Class,ID Number, 1g:Containers <br /> HM and Packing Group(if any)) 11'.Total 12.Unit 13:Nlasle Codes <br /> 1- ,• �No. Type Quantity WLNol, <br /> 2, <br /> t7 <br /> 3. <br /> 4. <br /> 14,Special Handling.inslructions and Addill rmalion <br /> 4,t t _ ....�.�r...����t f . '1 <br /> 1b. GENERATOff'S/OFFEROR"S DEf2TiFICATlO : I herebydealare Ihei Ifie con anis of (s consignment aredullyand accutsately descnbedtZ;ve by the proper shippl-ng name,and are classfrrad,packageai, J <br /> marked and labeledtplacarded,and are in all re pacts In proper condition for transport according to applicable inlernatlonol and national governmental regulations,I[azpott shipment and tam the Primary <br /> Exporter,i certify that the contents of this const nmeht conform to the forms of the afleched EPAAcknowledgmentot Consent. <br /> I certify that the waste minimization statement i arlrj4d in 40 CFR 262.27(s)(1f]am a large quantity generator)or(d)(if 1 am a sma <br /> Geell gaaniity gonerato)7s true, <br /> nralor 0 oror'a Printed/Typed ype ame. gna ure <br /> t y ay ,ear <br /> 6Trans <br /> 8-Intemallonai Shipments ❑Import to S. ❑Export tram U.S, `� Port ofenlryyexil:oiler sl nature for ex orts oni bateleaving U.S;: <br /> ,TransporterAcknowledgmentofRece1ptofMaledeanspn ert•Pdnie liypadName gnature <br /> I O r taon ay ear <br /> CL <br /> � Transporter Prinled pe Name - 'f ' gna we � -•z.. � fi ,.,",�''.�''.- � ( � I�_r:,E:. <br /> onth y ear <br /> 18.Discrepancy <br /> 18a.Disaeparncy Indicalion Space Quantity ❑7 e <br /> YP ❑Residue• 1_1 ParBal Rejection Full Rejection <br /> P18b. mate Fac(flly(or Generator) Manifest Reference Number. U,S,EPA 11 Number <br /> u-• Phone:natureofAlfernateFacllity(orG�nerator) tt➢� - <br /> �! :' Month Day Year <br /> 19,Hazardous Waste Report Management Method Cads(,e.,codes:for hazardous waste treatment,disposal,and recycling systems). <br /> 4. <br /> 20.Designated Facility Owner or Operator:Certification trecolpt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Ll <br /> Printad/iyped Name <br /> Signature -nth Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions ere i ibso ate. <br /> GENERATOR'$INITIAL CORY <br />