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Please print,or type.(Form designed for use on e Ito(i2-pitch)typewriter.) Form Approved.OMB No,2050.0039 <br /> -met ncy 4. <br /> UNIFORM HAZARDOUS I -Ge118fat0rllJNjMb81( page i of 173.7me Response Phone Manifest Tracking Number <br /> WASTE MANIFEST <br /> 0'115 1, F L E <br /> TUeneralot's Name and Mailing Address Address <br /> �Iwfdlff4r—entlhan ✓ <br /> mailing address) <br /> Generator's Phone: <br /> 6.Transporter i Company N ame I U.S.EPA' I0 Number <br /> 7.Transporter 2 Company Name <br /> U.S.EPA ID Number <br /> 8.DesignatedFacility Name and Silo Address--f-7 <br /> U.S.EPA 11)Number <br /> Facility's Phone: <br /> go, 9b.U,S,DOT Description(Inducting Proper Ship i;nq Name,Hazard Class,ID Number, 10.Containers 11,Total 12,Unit <br /> HM and Packing Group(if any)) 13,Waste Codes <br /> 1. No. type Quantity Wtjv0I. <br /> 0 <br /> 2. <br /> Uj <br /> 4, <br /> 14,Special Handling Instructions and Td—dilional Ini(mat on <br /> name;a <br /> OR'S C811TIFICATON, I'll, tbby 6616rd ih d <br /> 15 `GENERATORIMFF�q and are classliled,packago , <br /> marked and labeled/placarded,and are in all rosp'I in 0 condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consIgnmj:I o;if.P,:,r,ffi,terms of the attached EPAAcknowledgment of Consent, <br /> I <br /> `I-certify that the waste minimization statement(derill ed In 40 CFR 262,27(a)(if I am a large clutknifty.generator)or(b)(ifI <br /> : — me am a small quantio generatorps true. <br /> f3onpratorstOfferor'sPrInter ypedNa bignalute.. <br /> Per <br /> ,j W.International Shipmenth <br /> t— I R import it)U.S ❑Expod from U.S. Pod of enlry/exil: <br /> i5 Transporter signature for exports only): Date leaVing U.&: <br /> JX 17,Transporter Acknowledgment of Receipt of Materials <br /> LU <br /> � Trans rf Pit itedlTyped Name Signature <br /> 0 , �/- t� . I <br /> CL 41- ('A <br /> ont ay oar <br /> 'r. <br /> z Transporter 2 P(Intedfryped Name Signature month Dqy Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> Residue Partial Rejection <br /> Quantity ❑Type <br /> Manifest Reference Number: <br /> I= 18b,Alternate Facility(or Generator) U.S,EPA 10 Number <br /> LL Facilitys Phone: <br /> —W 18c,Signature ofAltormile Facility lot Generator) Month Day Year <br /> Z I <br /> 2 19.Hazardous Waste Report Management Method odoj(llo.,—codes for hazardous waste treatment,disposal.end repyclingsystems) <br /> (n <br /> LLJ <br /> 0 1. 2, 9. <br /> L20.Designated Facility Owner or Operator:(34iffifica on o receipt of hazardous materials covered by the manifest excelp t as noted In Item 18a <br /> PrinledfTyped Name Signature Month Day Year <br /> EPA Form. 870022.(Rev.3.05) Previous editions re obsolete, GENERATOR'S INITIAL COPY <br />