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I <br /> 0 C ✓�r� <br /> Please print or I pe.(Form designed for use on eil�e 1�-pitoh) f.1 <br /> �Agtrnelalot IP Nu nbar r p w`iCe I.) 1 Page <br /> 11'+f y p�r Yr g PP 50.0039 <br /> UNIF01�7 HAZAR OUS t 2 Pa e i of 3 Emer enc Res onse Phone 4.Manifesraaki g um or <br /> WASTE MANIFEST I'' l' i..} ° cit i 1, s.,rtf it r! £1 11 <br /> t Form Approved.OMD No,2 <br /> r <br /> S.Generator's Name andMailmg Address 004 ' w 0g> ,,i GenertrSSi(eAddress{ifdiforentthen mailr ) <br /> Generalor'sPhone: <br /> 6,Transporter Company <br /> U.S.EPA ID Number <br /> s;'rt�0 4d8) <br /> 7.Transporter 2 Company Name U,S,EPA ID Number <br /> 8,Designated Facility Name and Sile Address IIN Hffl�P <br /> U.S,EPA ID Number <br /> Vii.� >Ti1l�� l��r)iti'T(•( �iT-'1•(.Iv�'r !"�t:f=ty <br /> () <br /> tot t <br /> E <br /> Facilltys Phone: f�`•'1f f 1,t,a: 1 j'7 <br /> ga, 9b.U.S.DOT Descdpfion(including Propar Shipp hg Name,Hazard Class,ID Number, 10,Containers <br /> HM and Packing Group(if any)) 11:Total 12.Unit i3.Waste Codes <br /> 1 <br /> No, Type Quantity Wtivol. <br /> cti tVf:,+IC.{ . �r rt <br /> t1"0 .14)-LL' U' l <br /> ik i:€O hij:f. i.1' J. <br /> LLJ <br /> t9 2, ♦ � ,i <br /> i <br /> i <br /> 4, <br /> i <br /> 14.Special Handling Insiructtons and Additional Infor alto <br /> 13TjRPIB C1 .att13 f r <br /> P q } �y, <br /> a-fi t�iV (,tylJ S{+i itii��' ftt.�4 �'—1�ili"sV <br /> t•' ' <br /> 14, P6'�ftd r <br /> 15. GENE RATOR'810FFEROR'S CERTIFICATION: I lit reby,declare that the:contents of this consignment are.luliy and accurately described above by the proper shipping name,and are classified,package(li <br /> marked and labeled(placarded,anti are in all niapect In proper condition for transport according to applicable international and national governmental regulations,if export shipment and i am the Primary, y <br /> Exporter,I certify that the contents of this consignmer t conform to the terms of the attached EPA Acknowledgment of Consent, <br /> I certify that the wasle minimization statement id'enlirr in 40 CFR 262.27(a)(if I am.a large quantify generator)or(b)(if)am small quanlitytgeneratorf la true. <br /> Generator s/0fferor s Printedfryped Name r ` Signature Month Day Yaar <br /> -r 16.IntemaWt6 Sh1pments �f <br /> 2 ❑Impon to U.S. ❑Export from U.S. 'r Pi'doCenlryle 11; _ <br /> — Transportersignature(for exports only): Date leaving U.S.: <br /> IT TransporterAcknowledgment of Receipt of Materials - <br /> Transpor rIPdntetllfypadNama f i Signalufe Month Day Year <br /> Q Transpb e 2 not' ad, in S1r �. y <br /> gnaftrr nth""Day ;Year <br /> 18.Discrepancy I , <br /> 18a,Discrepancy Indication Space Ouanuh ❑ <br /> � T Ype ❑Residue ❑Partial Refection ❑Full Rejection <br /> 18b.A]Ia eteFacl11ty(orGenaretor) <br /> Manifest Reference Numbers <br /> U.S.EPA ID Number <br /> C1 <br /> Facility's Phone: <br /> Lo 18e,Signature olAllemate Facility(or Generata) r Month Day Year <br /> Z # <br /> 19.Hazardous Waste Report ManegomantMothod Codes(:a.,codes for hazardous wastatrealment;dispose);and recycling systems) <br /> to Uj 1' 2j 3, <br /> d. <br /> 20.Designated Facility Owner or Operator:Certification of ceipt of hazardous materials covered by manifest except as:nctadIn Item i8a <br /> Ll --- <br /> Piintecirryped Name Signature <br /> Month Day j ear <br /> EPA Form 8700-22(Rey 3-05) Previous editions ar—01 oir3te, f <br /> ).'':? , _ '1:•�r , ;:,i:t GENERATOR'S INMAL 'OPY <br />