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<br /> Please prlr t oP'lype'Form designed for use on silt (12-pitc1l)typewriter.)
<br /> 'Num or r � 2050.0039
<br /> UNIFORM NAZARUDUS 2,Poogo 1 of 3.Emer en y==2�
<br /> Manifest Traeking Number
<br /> WASTEMANiFEST { {,t�tt;r;;(lldf,.,ivG) is (. t# tt '"° � ppt Generator IDorm A roved,OMB No.5 Generators Nama and MaflingAddress b' .1 0 S,
<br /> Ganeraior s Sitmailing address)
<br /> C t ���s r�l A r� ��y:,(:c res; ��t:°
<br /> GA r 1
<br /> Generator'sPhone:
<br /> 6 T(ansporter 1 Company Name
<br /> INCI„ U,S.EPA'it)Number
<br /> iltll Illlf!]t )'i
<br /> 7.Transporter Company Name i
<br /> (,t_( lltqh3r'ftt);t+ tai; !?a�h� tO(�i u;S.EPAlONumber
<br /> 8,Designated Facility Name anteAddress i — m 1nit,
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<br /> lli #itii llll> itlit,a3};j{<i it3u : u.S,EPA IDNumaer
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<br /> Facility's Phone ir)t)t,r? r IC{l
<br /> ga, 9b.U.S.00T Descriplion(including Propir Sh ping Name,Hazard Cfass,ID Number,
<br /> HM and Packing Group(if any)) 16.Centainers 1L Total 12.Unit
<br /> No, Type Quantity WI./Voll 13.Waste Coda
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<br /> 4 I tt t.Z'ty �G�JIi8
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<br /> 14,Special Handling Instrucliohs and Additional informs ion
<br /> C13"a11 79;1 v Ei
<br /> (r HIR iii#k tti` Y # 1 i ll — (s, `:)i f srt t' V-11
<br /> 15. GENERATtlR'S1bFFEFttlR'5CERTIFICATION:I erebydaclare thatthe contents of this consignment are fully and:accurately descnbad above�till,the proper shipping name,and are classifiedpa k e'
<br /> marked and labeled/placarded,and are in all r�spe is in proper condition for transport according to applicable International and nationa1.9ovemmental regulations.if export shipment and I am the Primaryr`
<br /> Exporter,I cerilfylhat1ha contents of this consjgnm�ntconform 10 ihe'temu ottheadachetlEPAAOknowledgment of Consent.
<br /> I certity that he waste minimization statement Identified In 40 CFR 262.27(x)(ICI am a large quanifty generator)or(b)(Iii 110 a small quantity dnerator)Is trnd
<br /> Gonerator's/Offeroes Printedlryped Nam
<br /> Signature _ onlh" Day Year
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<br /> { �•~- r• /r � t.. f y,t•3' Il l f �� ,.,.,� ,
<br /> --r 16.internaUdna i Shlpmer)s r—�
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<br /> El to U:S. l_I Export from'U S, Port of entry/exit:
<br /> WTransporter s(gnatura(far exports only); Date leaving.U:S.: —'—--f— "
<br /> j 17.TransporterAcknowledgment of Receiptof Materials
<br /> Transportp,1 Printed[Typed N9me
<br /> Signature'
<br /> Month Day ! tear
<br /> QTrainspo r 2 nl" ped a a
<br /> � Signal re �
<br /> Month ay j Ya5i
<br /> f-
<br /> 18,Discrepancy
<br /> 188.Discrepancy indication Space
<br /> ❑ r—
<br /> QuantUy t—1 Type ❑Residue
<br /> ❑Partial Rejection ❑Full Reiecl'wn
<br /> 18b.Atlemate Facility(or Generator) Manifest Relate n0e Number.
<br /> t U.S.EPA ID Number
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<br /> LL Facility's Phone:
<br /> i
<br /> w 180.Signalure ofAltemate Facility(or
<br /> Month Day Year
<br /> 19,Hazardous Waste Report Management Method Codes Lo.;codes for hazardous waste treatment,disposal,.and recysiingsystems)
<br /> 4.
<br /> 2g,Designated Facility Owner or Operator:Certification.of ecalptof hazardous materials covered by the manifest except as nded In Item lea
<br /> Printed pad ams
<br /> 81 nature
<br /> Month Day Year
<br /> EPA Form 8700-22(Rev.3-05) Previous editions art ob olete, I
<br /> GENt=RATUR'S INITIAL trtaPY
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