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Please print it or type.(Form designed for use oil, life(12-pitch)typewriter.) t. Form Approved.OMB No,9050.0039 <br /> UNIFORM HAZARDOUS 1-Generator ID um or 2.Page 1 of 3,Emergency Response Phone 4,Manifest6Tracking Number <br /> ' <br /> WASTE MANIFEST <br /> iv k <br /> T 5enoraloes Name and MallinifA--ftess � A4 "194 I 00wq 3SKS <br /> G on a is IT—Site Address(If diffore nt than mailing addras a) <br /> Generator's Phone: ,r_�.,r � ' ' <br /> 6,Transporter I Company Name U,S,EPA 10 Number <br /> 7.Transporter 2 Company Name <br /> U.S,EPA ID Number <br /> J mt, <br /> 8,Designated Facility Name and Site Address U.S.EPA ID Number <br /> r:t;�J- <br /> Fadilly's Phone: 4 <br /> ga, 9b.U.S.DOT Description(including Prop t r Shipping Name,Hazard Class,ID Number, 10,Containers <br /> HM and Packing Group(if any)) No. Type Quantity 11,1[clal 12.iUnit <br /> Unit 13.Waste Codes' <br /> wl , <br /> 0 <br /> f, Y <br /> M."i <br /> 0 <br /> 3. <br /> 4, <br /> 14.Special Handling Instructions and Additional Informal on <br /> J: <br /> -1E Y <br /> �GENERATOR'$IOPPEROA'9'0-tRYI�ICAtib�i ffiliniby d6clifro 01611t <br /> !Mrd=a,�t abode tri p�4d�a-a 91Tping name,and are classified,packag ad, <br /> 7�, hi=a ts1of'IRI�' dl='Q'?el�dM�-(Ml <br /> marked and fabelMtplacarded,and are ftfall rospoc(s In proper condition for transport according to applicable InIsmationalarid national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of Oils cons!gnm nt conform to the terms of the attached 5PAAcknowledgment of Consent <br /> I 0411y that the waste artrilmizallorl statement danti ad In 40 CFR 262,27(a)(if I ama large quantity generator)or(b)(Iffoal"mall quandvgeneralot)101618. <br /> 1G61ieraIq?s/Qffo;ror's Printed/Typed Name Signature- Month Day Year <br /> IS.International Shipments <br /> impodFl <br /> ioi.s. <br /> F] Export from u,s. Pod of wry/ot: <br /> Transporter signature((or exports only): <br /> Data leaving U.S.: <br /> UX 17.Transporter Acknowledgment of Recollit of Materiels <br /> �2 Transportgrj'Printed[Typed Name signature <br /> 2 'or, ", Month "'U <br /> ay Year <br /> 41t-.;� I , e-- �' -i'9 - <br /> z� 4 <br /> Transpoffor 2 Prhted ff)(ped Nato . , —'. - 4�.', - <br /> SlAtvni-- -M$nth --Day-T�-W <br /> I&Discrepancy —7 —1 Partial Rjitelforl I I I <br /> 18a,Discrepancy Indication Space 0 Quen! El Type ❑Residue Full Rejection <br /> 18b.Alternate Facility(or Generator) Manifest Reference Number: U3,EPA ID Number <br /> LL Facility's Phone: <br /> (Z I <br /> LU Signature ofAllemato Facility(or To—neralor) Month Day Year <br /> U <br /> ,A 19.Hazardous Waste Report Management Method C des ji.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 20.Designated Facility Owner or Operator;Cediridatic n of,celpli of hazardous malotials covered by Vie manifest except as noted in item Joe <br /> Printedrryped Name <br /> Signature Month Day Year <br /> Ll <br /> EPA Form 8700.22(Rev.3.05) Previous editions ar ob1tolate. GENERATOR'S INITIAL COPY <br />