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Please profit or type.(Form designed for use on elite(12-pitch)typewriter,) Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 Genrry r ID N m 3 ® 2 Page of 3.Emergency ttOncy Respon:e P no 4. nffet Tra kin Number <br /> WASTE MANIFEST �JI 41r_ <br /> r 1 �j 0,10606317 FLE <br /> 9.Generatoes Nam and Generators Site" geese r cr4M ffian nmrkrtg address) <br /> 3 '8;t3-. <br /> CiGr 3ri1tuY5 Phone: > >.�i'i <br /> r,,Transrxrter I Gorpri me U S.EPA ID Number <br /> 7.T1,msfo,1es 2 nnanr Name U.S. A1D Number <br /> I <br /> N.Designated Facility Name and Site Addresa U.S.EPA ID Number <br /> Faclih s Phone: ` <br /> o 9b.U.S.DCT Descrlpticn(including Proper Shipping Name,Hazard Class,ID Number, 10 Containers ',1.Total 12.Unit 13.Waste Codes <br /> 1 itvi and Packing Gra.rp(if any)) No. I Type Quantity WI.Noi <br /> 1 <br /> UJ <br /> J <br /> W <br /> U <br /> to <br /> I <br /> j <br /> { <br /> 14,Spc :dHardbing strtutonsazldr�lff ana(inkxfriaton 9b' a 7oZ" $'36 .0 <br /> azo 131570-mSt ? <br /> 15. GENERATORVOFFEROR'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 /> Evporter,I certify that the contents o`this ecnsignmert conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste rrImmization 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 /> Ciurwrat n rinte(p yp antena ure on ay year <br /> l .r L <br /> 16.Imern..abooal Stiprnants r � <br /> F_ 0 Import to U.S. L f Export from U.S. Port of entry/exit: <br /> -- Transputer SWAure(for exports only): Date le"rig U.S.: <br /> CZ w 17.Transporter Acknowledgment of Receipt of Materials <br /> re Transporter 1 PrinWiTypod Name &gnaturey,/ ear <br /> z Trar�sportat 2 Pn'nt&d1Type4,Namq TOW <br /> 18.Discrepancy <br /> 18-Discrepancy Indication Space ((��'� rr�� <br /> Quantity LJ Type F—I Residue L_J Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> Fariiky's Phone: <br /> ® 1 c.Signature of Alternate Facility(or Generator) month– Daiv Year <br /> LU <br /> 19.`azardous Waste Report Management Method Codes(Le.,codes for hazardous waste treatment,disposal,and recycling systems( <br /> O 3 4. <br /> 20,beslwiat Facility Owner or Operator,Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed!ysignature K th Day jTear <br /> EPA Form 8700-22(Rev.3-05) Previous editions are atsolete. LiESICNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />