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, r r. <br /> s".SV 7S g..« }, 3. 1�_�.f'd7 ��rs <br /> Form Approved.OMB No.2050.0039 <br /> Please print or e.(Form designed for use on elite(12-pitch)typewriter) cking Number <br /> 1 Generator ID Number � a �/ <br /> 2.Page 1 of 3.Emer enc Res onse Phone 4.Manifest Tra n <br /> U RM HAZARDOUS (_( Er at r,lr t,s«k r 4 i. ._, ° 7, f t f <br /> ASTE MANIFEST <br /> Generator's Site Address(if different than mailing address) <br /> 5 Generator's Name and Maat <br /> iling Addre;1 1ss sd tt .�s�o$g ��xxyy� y <br /> ( ! . k.`f t 4 i , P}4s. ,^11„1# .. u»: Gold 3c•i`2 1;.. <br /> r+ "� eri l ti4�� €;tt(°1.1'Y t) <br /> !rdtix . xCA ` s :;j tri t4a f ` (.sf Sapt <br /> Cr 953,77 <br /> Generator's Phone: * '` _ <br /> 6 Trans rter 1 Company Name U.S.EPA ID Number <br /> U.S.EPA ID Number <br /> 7.Transporter 2 Company Name <br /> U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address , r1+ 1 •>.m j V_17tpOF, t (;( ( (.Irp,j r t <br /> ES 0 9tlIT H AV <br /> Facility s Phone: <br /> 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> 9a. No Type Quantity WL/Vol. <br /> HM and Packing Group(if any)) <br /> 1. TT <br /> r1 '14111-10 (ft? i (14 `)( j. {,XPiI,TI0 <br /> )� <br /> W a' 2 Uj <br /> _r <br /> C2 <br /> 3. <br /> 4. <br /> 14,Special Handling InsWcBonsandAdditionallniorma8on <br /> 9 <br /> M d TV"C <br /> 5�y q {�' <br /> '.I R 1 5,.. {i a ... .,€ N'4°r. V �-r-lir -r ":e F T-k p"f° r r(' 3 .:'"s j b# • °. F<4m3 P* a ey ° <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 f am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowiedgment of Consen <br /> cer8fythat the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I a small quantity @Hera true. Month Day Year <br /> GeneratoeslOfferors Printedlryped Name Signa <br /> 7 . <br /> 16.International Shipments' Import to U.S. ❑Export f om U.8 Port of entry/exit: <br /> Z Transporter signature(for exports only): Dake leawng U.S.: <br /> W 17.TransporterAcknovAeldgment of Receipt of Materials, Month Day Year <br /> i Transporter 1 Printa yped Name Signature <br /> NVt ` i* .� 4 y�W F 48ign-tw— Month Day Yea <br /> zQ Transporter 2 Pnmed/Typed Name <br /> 18,Discrepancy <br /> 18a.Discrepancy Indication Space E quantity -1 Type Type ❑Residue Partial Rejection ❑Full Rejection <br /> - Manifest Reference Number: <br /> U.S.EPA ID Number ' <br /> 18b,Aitemate Facility(or Generator) y" <br /> J ` <br /> uQ- Facility's Phone: Month Day Year <br /> W 18c,Signature ofAlternWe Facility(or Generator) <br /> a <br /> z <br /> 0 19.Hazardous Waste Report Management Method Codes(t.e.,codes for hazardous waste treatment,disposal,and recycling systems)' <br /> O 1 2. 3• 4. <br /> 5 <br /> 20,Designated Facility Owner"or Opar or;Certification of receipt of hazardous'materials covered by the manifest except as noted in ite a' Month Day Year <br /> PnntedlType me 1 Signature <br /> 16 1 r" 1 <br /> i43 DESIGNATED FACILITY TO GENERATOR <br /> EPA Form 8700-&Rev.3-05 PreVlOUS�editl0tis re obsole i / <br />