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it <br /> J'A A <br /> Plea5,9 pilrilor type.(Form designed for use on qlite'i2-Pllch)(ypewriterj Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS I L Generator ID l'umber 12�pagoll 3.Emergency Ra�ponso Phone-- 4.Manifest Tracking Number <br /> ff 01 1� F L E <br /> WASTE MANIFEST <br /> 0 1.1 <br /> 5.Generator's Name and Mailing Address Generators Site Address(If-aferent—1ha"aill'o address) <br /> General <br /> U.S.EPA ID Number <br /> 01 Iransp1mr,1 Company arae <br /> T.—Transporter 2 Company Name 11 <br /> U.S:EPA ID Number <br /> TN <br /> B.Designated Facility Name and SileAddress •; U.S,EPA ID Number <br /> Facility's Phone: <br /> 9a, 9b.U.S.DOT Description(Including Proper Ship)ng Name,Hazard Class,ID Number, to,Containers <br /> HM and Packing Group(if any)) 1 11,10181 12.Unit <br /> No. Type Quantity wt./Vol. 13.Waste Codes <br /> R <br /> Z Aw <br /> LLJ <br /> co& <br /> 4. <br /> 14.Special Handling Instructions and Addil-io-n—al fif—or rialtol, <br /> 1,3 <br /> C,I <br /> 15."d5NEOTOR'S/6'PFtROR'SOEgTIFICATIONf h re <br /> name,and are classified,packaged, <br /> marked and labeled/placarded,and are In all respects In proper COltdillon 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 consig)men conform to the terms of the attached EPA Acknowledgment of Coo'sent. <br /> that the waste minimization statement Iderififild In 40 CFR 262.27(a)(III am a large quantity genora(cin or(b),(11 am a small quantity generator)is true. <br /> Generators furlerors Ffinteciffyped Name titgnalUr I on Day Year <br /> :-j 16.International Shipments <br /> 0import(o .5. ❑Export from Uf Pori of entry/axil: <br /> Transporter signature for expels only): I -Da1e'leaving_U,S,: <br /> 17.TransporterAcknowledgment of Receipt of Materials <br /> Transpo a fintedrTyped Name Signaturp,- Month Day Year <br /> 0 <br /> CL <br /> C/) —Prnt—ednTp6d Ne 59 Vq <br /> Z <br /> Transporter <br /> Month uay year <br /> IL <br /> 18,Discrepancy <br /> 18a.Discrepancy Indication Space <br /> Quantity OType Residue ❑Partial Rejection EJ Full Rejctlon <br /> Manifest Reference Number: <br /> 18b,Alternate Facility(or Generator) U,S.EPA 10 Number <br /> =I <br /> u<- Facifitys Phone: <br /> 0 <br /> LU 18c,Signature of Alternate Facility(or Generator) <br /> Month Day Year <br /> ZI) <br /> 19.Hazardous Waste Report Management Method Codes(t.�.,codes for hazardous waste treatment,cheposal,and recycling systems) <br /> 12. <br /> 20,Designated Facility Owner or Operator.Certification)ffe aljoto,(lMrdouo maleflaiscovered;-by the manifest except as noted In item-18a <br /> Printed/Typed NameSignature," <br /> onth Day Year <br /> EPA Form 8700-22(Rev,3-05) Previous editions are)bs <br /> DESIGNATED FACILITY TO GENERATOR <br />