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Please print or type.(Form designed for use on elitp(12 pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> '36nerator ID Number 2,Page llof 3.Emergency Response Phone 4,Manifest Tracking Number <br /> UNIFORM HAZARDOUS III,, I ! (11"6 1�-A � <br /> MANIFEST {rt9 A SKS <br /> "WASTE M 10 0-521'28 6 <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different then mailing address) <br /> 5 1 <br /> (T) 91- <br /> Generators Phone: `12 b <br /> 6.Transporter I Company Name U.S,EPA ID Number <br /> 10 01.0 0 1 t 1 "3 <br /> I.J.1,IN Y 1-3"1. fmc- <br /> 7.Transporter 2 Company Name U.S,EPA ID Number <br /> 8.Designated Facility Name and Silo AddressHQR80115 MIN JOU.S,EPA ID Number <br /> CLEAN k-St'. Ll-l", <br /> MA 11E.RRY5(1.3iA ROAD <br /> Facility's Phone: <br /> 93, 9b,U,S,DOT Description(including Pmpur$hIppi g Name,Hazard Class,ID'Number, 10.Containers 11.Total 12,Unit 13,Waste Codes <br /> HM and Packing Group(if any)) No, Typo Quantity. WI.Nol. <br /> I <br /> NON Ri'i-41 HiVARI)OUS 11%1AQ1Tf.-" 9111.31-11T!"31 <br /> J,-.13N It <br /> Z 2. <br /> LU <br /> 3. <br /> 4. <br /> 14—.Spe clal Handling I pstructions and Add I tional In formall or i <br /> TGO 9", ('-9 11-'.1 C-,4 C5 (:3.3,3 :�,j <br /> '`4 lvdkC.,J*"N1K-.'NCY 11-:1 x'I-AA-M O'K <br /> 1r"141TM Tr't 0171-OTIV 'I'MMU, <br /> 10H 00/ r" I co-ntents of this StgnMen <br /> con a 4r*1!nilaImp'llaiely deErl .ma,,!ard are classified;packaqeo,� <br /> 16. r.ENEPATOR'SIOWFF9R'�CE,�IRTIFICATiCiN"I I ha'aby declare that the bfi;� <br /> marked and iabeled/placarded,and are In all resoacts p <br /> In ropercondition for transport according to applicable international and national governmental regulations,if export shipment and I am the Primary <br /> . <br /> Exporter,I certify that The contents of this conslig6man:conform to the forms of thoaltachad EPAAcknowledgmentofConsent. j <br /> """' <br /> ce a waste minimizationsstatement ld�ntlfled In 40 CFR 262.27(a)(if.I am a large quantity gernaratot)or(6(iff am a small quanuty generator)Is true. <br /> - I signature Month Day !Ycar <br /> Generators/Offerors roes Printedrryped Name <br /> ,are le"sloir' <br /> �7 <br /> -j 116.International Shipments L1 Import to VIS. El Export from U.S. Pon ofentry/exii: <br /> Transporter signature(for exports Only): I Date leaving US.:---I <br /> WW 17,Transporter Acknowledgment of Receipt of lvlatedal� <br /> i274111,P6ntoVvped-Name signature Month Day Year <br /> 0 TI-18"p— <br /> U) ' <br /> Transp&tbr 2 Pl-iintedfTyped NA-0 Signature Molith Day Yek <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space QuentilyEl! Type El Residue E 3P, <br /> 01.1 Rejection El Full RajWlo <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S,EPA 10 Number <br /> Facility's Phone: <br /> Month I Day Year <br /> w 18c.Signature ofAllarnale Fadfity(or Generator) <br /> 19.Hazardous Waste Report Management Method Codes(.e.,codes for hazardous waste tioatmant,disposal,and recycling systems) <br /> V) <br /> LU1 21 <br /> 20.Designated 0111ty owner or Operator:Cerlilicailop of.r MOO hazardous materials covered by the manifest except as noted In Item 18a <br /> Printedllypa )a Signaturee <br /> Month Day Year <br /> 1AL COPY <br /> EPA Form 8700-22(Rev.3-05) Prevlous.edfllonsare ob.ofate. GENERATOR'S INI <br />