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M Cl) -0o0 <br /> CD X� �D O !�Oc4i' <br /> n O CD <br /> - 3 00 � <br /> �# N � <br /> O vre�— --�-�„--r3r. . CD A p X <br /> M. lint <br /> M Please print or type-(Form deWgned for use on elite 12•' IIII 1 �+III II I I�If II III - <br /> 2 UNIFORMkAZARD0U5 t.GeneratorlDNumberplich]typewnter.} �IAIuN�G� FormApprovetl.OMBNo.2050-0039 <br /> WASTE MANIFEST 2.Page 1 of 3.Emergency Response Phone —ral Tracking Number O W <br /> 5.Generators Name antl Mailing Address <br /> 010788843 FLE W W <br /> Generalors Sile Address(if different gran mailing address] <br /> r <br /> GeneratoYs Phone: � <br /> Transporter 1 ompany ame � <br /> U.S.EPAID Number CD <br /> 7.Transporter 2 Company Name ` " Q <br /> U.S.EPAiD Number <br /> B.Designated Facility Name and Site Address <br /> ,,,, , ;.1: U.S,FPA ID Number O <br /> Facility's Phone: <br /> ga- 91).U.S.DDT Descripfion(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers it.Total rt2,Unit 1 D <br /> HM and Packing Group(if any)) <br /> 3 3.Waste Codes <br /> 1' ,'I I':• I� Na, Type Quantity WiJVoI. <br /> rli ll'ol:l <br /> 1 1 .7 <br /> 2 2. <br /> W <br /> C7 <br /> 3. <br /> 4, <br /> 14.Special Handling Inshacfions and Additional Information <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare[hat the contents of this consignment are fully and accurately described above by the proper shipping name,and are rdaWffied,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable imematianal and national govem"rhal regulations,If exportshipmentand lam the Primary <br /> Exporter,I certify that the contents of this consignmentconform to the terms of the ateChed FPAAcknowledgment of ConserrL <br /> I certify that the waste minimization statement identified in 40 CFR 26227{a)(if I am a large quantity generator)or(b)(if I am a sma4 quaintly generator)is hue. <br /> Generales! erods PnntedlTyped Name brgnamro, on a ear <br /> rj 16.International Shipments I� <br /> i— ❑Import ro U.S. ❑Export from U.S. Port of enlrylexlt: <br /> ? Trans orter si nature for ax ons till : Dale leavin U.S._ <br /> 17.TransporterAckirmledgmenl of Receipt of Malerials <br /> nature <br /> a Transporter 1 PnntedfTyped Name 9 ont ay ear r' <br /> a <br /> a rrspoder 2 PnntedlSyped Name Signalonj onth ay ear # <br /> �I1 <br /> 10 <br /> T7ecrepaccy <br /> I 1 Aa,Discrepancy indication space ❑quantity ❑-we ❑Residue <br /> ❑Partial Rejection ❑Full Rejection <br /> I <br /> I <br /> I I Manflast Reference Number: <br /> Atemale Fadlily(or Generator) CZ CD <br /> U.fi EpA ID Number <br /> 1t n <br /> Qt <br /> Phone: <br /> sigtrD nO <br /> nautG ) <br /> Manch Da <br /> a Y Year I Q <br /> X <br /> a 1�e rlazarda+s Waste Report Management Memod Catles{i.e.,modes for hazardous waste treaMsnl,disposal,and 1: h1:111 systems) <br /> z. 3. 4 N <br /> r er or Opemmr Certifuanon of receipt of hazardous materials covered by the manifestaxcept as noted in Item 1 iia C.)1 <br /> 'J-Jeugnaled Facility Oren 1? � <br /> Prim edrry*Name signature O <br /> O Month Day Year W <br /> EPA rm 8700.22(Rev 3-05}Previous edifions are otrsolete, ` N <br /> 1 O <br /> 0 GENERATOR'S INITIAL COPY Tn <br /> O ,v+'It1, ,! <br /> _ <br /> CD <br /> (D <br /> V I <br />