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Please print or type.(Form designed for use on ellte(12-pitrh)4pewriter.) Form Approved.WE No,2050-0039 <br /> UNIFORM HAZARDOUS 1 Genf1pr I Number 2.Page;1 of 3:Eme pricy espouse Phone, . 1 4.Mani estTracking Nurrtb r <br /> FLE <br /> WASTE MANIFEST r s.n_�e s 1.art,C?- •l n P•_' x P A i).�J. 9 <br /> 5.Generator's Name and Mailing AddWsss— Genetdtdrs S''01Ad&6ss'(If different than mailing address) <br /> Tray a`r3)f <br /> Generator's Phone i fi,ad u4 fI v 7 <br /> B.Transporter 1 Company Name U.S.EPA ID Number <br /> Rk--.`'kvF-riviTE}.,ff4 unn-ori. ki;itnr t?x9! (�t:�t°tdbit?t!S <br /> 7.Transputer 2 Company Name U.S.EPA ID Numtier <br /> l(r <br /> S.Designated Facility Name an rte cess, U.S.EPA ID Number J <br /> 0-S CP?t <br /> Hrgihtxax sS,15 rniieW sa:sr rS 8e:tlp <br /> 6oally,WPM)a <br /> Fadites Phone: M!3 13_ <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(f any)) No, Type Quantity WILNol. 13.Waste Codes <br /> OFUN 8"I�wasi44 Fkgalf °b1 s Liovid'kY_O.S.}-E; PC- jo lc_a!q r% '`�C...i ( � �1.+5 ��� -'al._ rawl <br /> LU <br /> Z 2. <br /> Non rGs:lw H ia,i�td eii5 4ncQ'A j;ts S i �t� I ;,� r�,�fio r� ,L. <br /> > -.. . <br /> 3. JAN2 ` 201 <br /> 4. ENV ' 7NNIc Y i'-AL AEAL <br /> 0EPA TME T <br /> 14.Spe�ciiall Handing Instructions and Additional Information ,a� y "S:'� M{� y .`�'� <br /> q <br /> 9b.I RG��71 tw s <br /> EWERGENCY CONTACT JEFF RHODES <br /> tll. GENERATOR'SIOFFERMS 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 intemational and national govemmentaI reg ulafions-If export shipment and I am the Primary <br /> ?j?' Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment 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 generators true. <br /> t ratorslOfleror's PnntedrTyped Name 'Signature Montb Day Year <br /> 4` ` <br /> `s`JJ 16.International Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> " Transporter signature for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> a Transporter Pnntedfryped Name - r / h # ignature �y ontt� Day Year <br /> IL <br /> Z Transporter 2 PnntedlTy�ed Name l Signature r f/ Month Day r Year <br /> H- i 1, �.4r+,.;q ...�1 ,,,,.p--.^•,���' ' Y;,,'`-.: �-� <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ QuantAy ❑Type El Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> _J <br /> U <br /> LL <br /> Facility's Phone: OCT 03 <br /> w 18x.Signature of Alternate Facility(or Generator) Month: Day Year <br /> 19.Hazardous Waste Report Management Method Codes(.e.,codes for hazardous waste Ueatrnent,disposal,and recycling sya*m) <br /> 0 1. 2. 3. 4. <br /> 14 <br /> 20.Designated Facill0 Ownei or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in hem 1 B <br /> Pdntedfrvoed.flatre,/. r �� Slgnafue Month Day <br /> Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />