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Please prat or tvoe (Form tsesgned for use on elite(12-oltchl typewrite'. Form Approved OMB No.2050.0039 <br /> f UNIFORM HAZARDOUS 1 Generator ID Number 2.Page 1 of 3 Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST F L E <br /> Gwwralsv s Naim:dell kfuuru3 AMlrass 5omerafvfs 5 tc Address Ir dilfen:at I ran mar&rr}address) <br /> I <br /> C ri'mlo%s Phone: <br /> F T1,1fumm f Cnnti any Name U:5 EPA Ill NurN,xw <br /> F anspmrrr 2 Cxrrpx�Y Name U S EPA ID Number <br /> 8 Designated Facility Name and Site Address US EPA ID Number <br /> Facility's Phone. <br /> 9a. 9b U,S DOT Description(including Proper Shipping Narne,Hazard Class,ID Number, 10 Containers 11 Total 12 Unit <br /> HM and Packing Group(if any)) No Type Quantity Wt Not <br /> 13 Waste Codes <br /> 1 <br /> O <br /> W <br /> Z 2 <br /> W <br /> C7 <br /> t 4 <br /> 1 1 a 5Uii ill Handling In5V++thWKand Addlflp4lJl Lnfppn.7hlYr <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent <br /> I certify that the waste minimization statement identified in 40 CFR 262 27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generators erors Pnntedffyped Name tiignature Month L)ay Year <br /> 1S Intrma5e Shipments <br /> ❑Import to U S ❑Export from U S Port o1 entrylexiC <br /> Tfaft4ansr s'nature ffoir exporw only): Dula I_ U S.- <br /> 17 Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 PrinleWTypecl Name Sgrialum M010 t3 <br /> Z Transyomer2 Prinfaii yped Name S!gnalure Month Day Ycair <br /> 18 Discrepancy <br /> 18a Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifesl Reference Number: <br /> 16b Almmale Facilfly(or CNueralcir) US EPA ID Number <br /> J <br /> U <br /> a <br /> LL FaCiii s Phone: <br /> Lu 18c Signature of Alternate FacTiry(or Generalor) Month Day Year <br /> a <br /> Z <br /> 19 Hazardous Waste Report Management Method Codes(i e,codes for hazardous waste treatment,disposal,and recycling systems) <br /> " 2 3 4 <br /> 20 Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Pnnlrnlr3yrxd^isr+Y Si�natur[ Morilh tray VWT <br /> 1 l <br /> EPA Form 8700-22(Rev 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />