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nt or typo;(Form designed for use on a ite 2-pitch)typewriter,) Form Approved,OMB No.2b60-0039 <br /> 'NIFORM HAZARDOUS 1 1,Generator IDN Imb 12,Page i0f 3.Emergency Response Phone KManitost Tracking Number <br /> 006 <br /> WASTE MANIFEST 4665 <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than melting address) <br /> Generators Phone: c'i <br /> 6,Transporter I Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> i I;Y <br /> Facility's Phone: <br /> 9a. ft U.S.DOT Description(including Prope�Shlp Ing Name,Hazard Class,ID Number, 10,Containers IIJbial 12.Unit 113.Waste Codes <br /> HM and Packing Group(if any)) No, Type Quantity VVIVOL <br /> A-i' <br /> 2. <br /> LLJ <br /> 3. <br /> 4, <br /> 77—Special Haindling—Insituctions and Additio at on <br /> In, <br /> "A' <br /> I,4t6y dti&drie[fi PM—Allnt-,�'Ah; t 1 rdl-1 I!; 0-,IbF fiename,end are classiflod,paolwq'ad, <br /> �76' Qe'A ate as, <br /> marked and labeled/placarded,and are in all r pacts in proper condition for transport according to applicable international and lionalgovemmen I regulations.if export shipment and I am&Primary <br /> 8 <br /> Exporter,I cerflty that the contents of this conTignm mt conform to the terms of the aftached EPAAcknowledgment of Censer. <br /> I cortify that the waste minimization sta(ementlident fled In 40 CFR 26127(a)(Ifl am a large quantity generator)or(b)(111 amsmall quantity p4rator)Is true. <br /> Geri&atoesfflfferoes PrInted[Typed Nam Signature.,,. Month Day Year <br /> I IA I <br /> -j 16,International ShIpme 7 Is 0 Import tc U.S. ME port from U.S. � Port of anlrylaxfl: <br /> ttTransporter signature(for exports only): Oate leaving U4.: <br /> ir 17.TransporlerAcknowledgment of Recolpt ofmatooals <br /> Transpodor:I'Pdnte yp <br /> ad Name <br /> Month Day <br /> Z <br /> 4 <br /> 6, <br /> 0 <br /> (n -[KN1io3nW1Rh--L-Tay A��ky <br /> Z TmnsPrfbr`ZPdt1ladrTjp6d Wine <br /> ear <br /> ifl.Discrepancy <br /> 18a.Discrepancy Indication Space El Quo illy ❑Type El Residue El Partial Rajed,n Full ReJo'tion <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) US,EPA ID Number <br /> :3 <br /> Foclifty's Phona: <br /> at Facility(or Generator) y Year <br /> uj 18c.SignalureofAltern a Month Do <br /> Z <br /> 19,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 11 1 2. 3. <br /> 20,Designated Facility Owner or Operator:Certification(frecellit of hazardous.materials covered by the manifest except as noted in Item 18a <br /> Printecirryped Namo Signature Moni,h Day Year <br /> I ft <br /> EPA Form$700-22(Rev,3-05) Previous editions ire obsolete, GENERATOR'S INITIAL COPY <br />