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Please print or type.(Form designed for use on elite(12-pitch)tyAllpewriter.) Form Approved.OMB No.2050.0039 <br /> n 1 of 3 Emergency Response Phone 4 Manifest Tracking Number <br /> UNI".STE MAIIFESOUS 1.Generator ID Number 2,page t # �� <br /> = , b � � � <br /> 5.Generator's Name and Mailing Address Generator's Site Address{(if different than mailing address) <br /> � <br /> #jai t <br /> Generator's Phone � �° `. <br /> 6 Tragsj�orjer 1 Company Name. U.S.EPA ID Number <br /> - <br /> r BT S r#If .S 13}#,,. .' _ <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address MAO <br /> . F .a I, U.S.EPA ID Number <br /> ,3-:-13i. "t;ia 't I i (AY,'-, <br /> Facilitys Phone: <br /> 9a, 94.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)) <br /> No. Type .Quantity wt./Vol. 13.Waste Codes <br /> t, (, <br /> O 5 r ) OIL <br /> X.. <br /> Z 2. <br /> W <br /> 0 <br /> 3, <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> ' ', A 11 C1,JI s..34 <br /> 15.'GENERATOR'SIOFFEROR'S CERTIFICATION:"I hereby declare that the contents of this consignment are fully and aocyrately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/plagarded and are,in all respects in proper condition for transport according to applicable intamafif <br /> gland national governmental regulations.If export shipment and 1 am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgmenl of I certifythat thewaste minimization statement identified in 40 CFR 282.27(a)(if I am a large quantity generator)or( am a small,quantity generator)is true. <br /> Generator's/Offeror's PrintedlTyped NameSignature 77T.— <br /> > Month Day Year <br /> tom. <br /> 16.Intemational Shipments <br /> 1- ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Z <br /> Transporter signature(for ex orts onl <br /> Y) Date leaving U.S.: , <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> o Transporter 1 'nied(ryped Name Signature Month Day Year <br /> aE r <br /> •. H <br /> ZZ Transporter 2 Prifed/TYPed Name Signature. Month Day Year <br /> 18.Discrepancy <br /> Ise.Discrepancy Indication SpaceQuantity ❑T e <br /> yp ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) <br /> U.S.EPA ID Number <br /> L) <br /> ua- Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Z ,. <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,"disposal,erfd recycling systems) <br /> LU <br /> 1 �r 2. 3, 4. <br /> c# <br /> 20.Designated Facility Owner.or Operator.Certification of ieceipt of hazardous materials covered by the manifest except as noted in[ten)18a <br /> Plinted/TypedName r- Signature . Month , Day Year <br /> EPA Form 8700 22(Rev,3 05) Previous editions are oli olete. -n DESIGNATED FACILITY TO GENERATOR <br />