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."Please print o.typo.(Form designed for use on elite(1 -pitch)typewriter,) Form Approved,OMB No.2050.0039
<br /> UNIFORM HAZARDOUS 1 Gasnoralorember Z Page 1 of 3;Emergency Responso Phono 4,Manifest Tracking Number
<br /> WASTE MANIFEST ai GflLN1�31�6@.1 Tri) Ea0 ), )���'641ti`1-4,6e'�1,�ir0
<br /> 5.Genorator's Name and Mailing Address Generator's Site Address(if dilterent than mailing address)
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<br /> Generator's Phone: t }••r,•/t
<br /> 6.Transported Company Name U.S.EPA 10 Number
<br /> 7.Transporter Company Name U,S•EPA ID Number
<br /> 8,Designated Facility Name and Site Address + Y( �y S ENyy U.S.EPAiD Number
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<br /> Facility's Phone:
<br /> ga. 9b.U:S.D T Description(including Proper 5hippl g Name,Hazard Class,ID Number, 10,Containers 11.Total 12,Unit 13,Waste Codes
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<br /> HM and Packer Group(if any)) No. Typo Quantity WilNol.
<br /> 1 ldC�p,; i�ff')lu F�la,tt:; litlL �;i riilt l«1G1`rlh: t1f J.C7�i i+t+f f? };;;
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<br /> 14,Special Handling instructions andAddilional Infos�auo r 3
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<br /> 15. GENERATOR'S10FFEROR'S CERTIFICATION:1 I he eby de are ittat lite co'n anis of th s cons(gnment are ul y and acc.r y ascribe above'y i proper shippingname,and are ciassi6ed,package
<br /> marked and labeled/placarded,and are in all respect's k proper condition for transport according to applicable International and national governmental regulations•if expos shipment and l am the Pnmary j
<br /> Exporter,i cortifylhat the contents of this consigrjmen conform to the terms of the attached EPAAcknowledgment of Gonsaml,
<br /> I cortify,that the waste minimization statement iden1me In 40 CFR 262,27(x)(If l am a large gwIllygenerator)or,(b)((If l am a smolili.quantity:generator)is true.
<br /> G6noialorslOfferor's Prinlectlyped Name I Sign # f Month Day year
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<br /> —� 16.International Shipments
<br /> i— ❑Import to U.S, Fl.ExpodQrom UA Port of entry/exit:
<br /> Transporter signature(for exports only): I Date leaving U S,:
<br /> 17,Transporter AcknmOodgment of Receipt of Materials
<br /> Transport cA1PdntedtTyped Name f;I Signature Month Day Year
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<br /> 12-21
<br /> Tran3p'orte 2 Ps t ped aye Sign m. �Month Day Year
<br /> 18.Discrepancy
<br /> 18a•Discrepancy Indication Space El Quant 1:1 Type ❑Residua ❑Partial Ra)ecllon ❑Fuli Rejection'
<br /> Manifest Reference Number:
<br /> 16b.Alternate Facility(or Generator) U.S.EPAID Number
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<br /> 11 Facility's Phone;
<br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year
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<br /> 10.Hazardous Waste.Report Management Method Cod as(L „codes for hazardous waste treatmsnl,disposal,and recycling systems)
<br /> U.1 1• 2.i 3. ��4, I
<br /> 20.Designated Facility Ovrneror Operator:Certification of tofpt of hazardous maleriels covered by the manifest except as nded in ilone18a-
<br /> Printed/Typed Name Signature Month. Day Year
<br /> EPA Form 8700.22(Rev.3.05) Previous editions are Jobs(late. GE. , :X)
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