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<br /> Form Approved.OMB No.2050-0039
<br /> Please print or type,(Forna.desioned for use on elite'12-plIch)typeVititer.) 4.Man eat Tracking Number
<br /> 1,Generator ID Number 2,page I of 3.Emergency Response Phone
<br /> UNIFORM HAZARDOUS 00 SKS
<br /> WASTE MANIFEST I Generators SlIoAddre if I r I than I jailing address)
<br /> 5,(;'enemke ame and Mail!gAddre 9
<br /> 2.p,,,n 4,6
<br /> ID Npnllr�
<br /> type,
<br /> OUS .....
<br /> WASTE MANIFEST
<br /> T,a
<br /> � na,,t, am,and M1il1,qAdde
<br /> ; 1 6,
<br /> Generalor's Phone; �-&i,
<br /> U,5.EPA ID Number
<br /> 6.Transporter I Company Name -W,'
<br /> • ---LU,—SEP—AIDNumber
<br /> ',
<br /> 7.Transporter 2 Company Name
<br /> US,[:FA 11J NUM061
<br /> -8,Designated Facility Name and SAOAadress
<br /> Facility's Phone:
<br /> 98, 9b,U,S-DOT Desadpilon(Including Proper Shipping Nome,Hazard Class,ID Number, 10,Containers 11.Total 12,Unit 13,Waste Codes 1
<br /> HM and Packing Group(if any)) No, Type quantity wtwol.
<br /> 301
<br /> p"-1
<br /> Z 2,
<br /> LU
<br /> 3,
<br /> d.
<br /> td.special Handling Instructions and Additional In otmaill n
<br /> 4
<br /> T3'
<br /> a=1,l Handling Inst,,,Uw,and Additional l7oim.�flh
<br /> 3 V�3
<br /> 'Y 4,
<br /> RA 7R
<br /> a'01
<br /> t-tMACATION:I t allorial governmental regulations.if export shipment and I am I
<br /> =��, lie Prl
<br /> er
<br /> 16. 'GtNERAT6R'8l0F AD ]cable Intemationsl6nd 11
<br /> pec[s in proper condition kit transport according to applicable rd
<br /> marked and labelediplacarded,and are In all tis
<br /> Exporter,I cerbly that Itto contents of this consli1nmel,conform to the terms of the attached EPAAckn6vAedgment of Consent.
<br /> 21(o)(if I am a large quarilityge,nerator)-or(b)(III am a small quantity:generator)Is true.
<br /> 1 certify that the wtsstaininimizagon at lemantld— dIn40CFR262.
<br /> "zo" in, Day year
<br /> me
<br /> Year
<br /> Signature
<br /> no,et6e.410iferars Pdn1adfryped Name T
<br /> —j 16.International Vpments ❑ 0 Expofrom U.S. Pod of entry/oxit:
<br /> Import wuz,
<br /> Date leasing U,S.:
<br /> Transporter signature(for exports only):
<br /> 13e-"17rTranspoderAcknowle ment of Receipt of Materials — tonih Day Year
<br /> -------------
<br /> Signature
<br /> e,
<br /> Transpo 0 Prints yped Name
<br /> 0
<br /> pay
<br /> Year
<br /> Signature Month
<br /> Transporterz rineoll ad Name
<br /> drr
<br /> y y
<br /> 18.DiscrepancyResitlua Partial Rej.,tion Ful(Rei❑
<br /> 18a.Discrepancy indication Space ❑Due intily ElType
<br /> Manifest Reference Number:
<br /> U:5,EPAfD Number
<br /> 18b,Alternate Facility(or Generator)
<br /> '
<br /> U<- Facility's Phone: Month DayYear
<br /> LU 18c.Signature or Alternate raulay{01
<br /> 19,Hazardous Waste Report Management Method ��s(fe.,codes for hazardous waste trealmo I,disposavand recycling systems)
<br /> UJ
<br /> aterials coverad)y the an rilfeat except as noted in Item 18ia
<br /> of receipt of hazardous m I q -- Day,
<br /> Slqnatura`"�
<br /> !0.Designated Facilily.0wrier or Operator,uemn,E
<br /> Printedffyped Name
<br /> GENERATOR'S INITIAL COPY
<br /> EPA Form 8700-22(Rev.3-05) Previous editions ar obsolete.
<br />
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