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Please print or type. (Form designed for use on elite (12-pitch) typewriter.) Form Approved. OMS No. 2050-0039 <br /> UNIFORM HAZARDOUS 1 . Generator <br /> ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number <br /> WASTE MANIFEST .,� . . - - _ oK ,... FLE <br /> S.Genemtols Name and Mailing Address - _ - - Generator's Site Address (if differentthan maing add ess) <br /> XMol ,r � ,.y <br /> '- lZtE <br /> 6l'ransporter'r t0mpany Name- -- - - -- - -- - . _ <br /> -- ------ - - - - -CID# <br /> ,_Ls. EPAID Number <br /> � ��p <br /> 7 porter 2 Company Name r�noWUWI <br /> U.S. EPA ID Number <br /> i+�it40fi542z <br /> 8. Designated Facility Name are Site Adtlress U.S. EPA ID Number <br /> 27Xl E, t 'tth 8• Rt5 14{by; ��21 <br /> Yell i2C ; IUe <br /> Facility's Phone: <br /> ea. go U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit <br /> HM and Packing Group (if any)) ��.��y} �y� �j��� No. Type Ouantiry WGNoI. 13. Waste Codes <br /> O 1 s 1111 So 03 m.ara / <br /> r..,85 Wt <br /> 2. : PCB P w2 <br /> ZCD <br /> - - I <br /> 3 � <br /> 4 <br /> 14. Special Handling Instructions and Additions Information <br /> PtCJa3 Nlfrtte► A'" T'9 DWANKIA u: D1®iQ4Y <br /> 17"" rnev- <br /> ale kewq <br /> 16. GENERA70R'SIOFFEROft'S CERTIFICATION: Ihemby declare that the contentsof 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 regulators. If export shipment and I am the Primary <br /> Exporter, I certify that the contents of this consignment conform to the tens of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste mnimizar6risruementid9rifili in-40-CFR 262:2T(a) (ff l am a large quan8ty-genemtor):or(b) (T l amasmalfquantity generator) is true. <br /> Generators/ORenfFS P ted/Typed Name igna ure - Month Day Year <br /> 16. International Shipments <br /> r— ❑ Import to U.S. ❑ Export from U.S. <br /> --'Part of entry/exit: - <br /> Transporter signature (for exports only): <br /> Date leaving U.S.: <br /> U.1 17. Transporter Acknowledgment of Receipt of Materials <br /> OTransporter l Pnnted/Typed NametI I- ignature .Month ay ear <br /> z Transporter 2 Printe /Types Name <br /> Signature ' <br /> _ 9 Month Dayrear, <br /> 18. Discrepancy - <br /> 1Ba. Discrepancy Indication Space ❑ quantity El Type <br /> ❑ Residue ❑ Partial Rejection El Full Rejection <br /> — - - Manifest Reference Number: <br /> 18b. Alienate Facility (or Generator) - t0idumb <br /> ZiU <br /> ' LL Facilit 's Phone: <br /> DID 18c. Signature ofAllernate Facility (or Generator) Month Day Year <br /> Q <br /> Z <br /> N19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> 1 . 2. 3. <br /> _ 4. <br /> 20 Designated Facility Owner or Operator: Cerdficafion of receipt of hazardous materials covered by the manifest Ocept as noted in Item l se <br /> Print arryped Name ;1 i Signature Month Day Year <br /> \Z4\\j G�Y �, _ N. <br /> EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. , -r DESIGNATED FACILITY TO GENERATOR <br />