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tse- 7 <br /> Pleasennt,.gr <br /> p type:{Form designed for use on elite(12-pitch)typewriter.) <br /> U4 1 HAZARDOUS 1 Generator ID N*ber Form Approved.OMB No.2050-0039 <br /> WAS MANIFEST )a ; 2•Page 1 of 3.Em a cy R s nse hyne_ 4;Manifest Tracking Number, <br /> ` b � m J <br /> � � <br /> eretor's Name and MaiOng Addressn*5 '96205 <br /> Z oU t- Gel t� Generators Site Address(if different than maikng address) <br /> 13 S0 9• ���: 1t aS'(i . i; tit Q <br /> FRAC �`ttV-1 ' t•' 47 tt cc��� � t7#�f f�€ tc !ie%r;- <br /> e ffFt�4t @k�S7 ff t 7.tT iG1 S i <br /> Cif 9SW t7 r°` J7 c i e <br /> Generators Phone: r U' �"' is 7! z ;a s l�; e, <br /> 6.Tta <br /> 7 N ( U.S:EPA ID Number <br /> 7.Transporter 2 Company Name <br /> U.S.EPA ID Number <br /> 8.Designated FacilityName and Site Address <br /> i ( 7( ( TF .ttnl°.i r cr <br /> 68 - ( AVE. <br /> t EPAIDNumber <br /> Facility's Phone: <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, <br /> HM and Packing Group(tf any)) 10.Containers 11.Total 12.Unit <br /> 14-7RGRA <br /> y�p (: t : iJU�S G�t�,O,TC, )..,t'.C,1uj No. yTYPe Quantity Wt Nol. 13.Waste Codes <br /> W <br /> W 2' <br /> CPO <br /> 3. _ <br /> 4. _ <br /> 14.Special Handling Instructions and Additional Information L,4 Qcg y <br /> , <br /> Y5.f�e y Q �yy �k �}�k Q �•'�" '$ � ^�'�$ [ .„mss, t�•s { �( }$& ,[ 'j ( , <br /> GENE <br /> SUP <br /> 3.`# °m' . <br /> 15: GENERATOR'S/OFFEROR'S CERTIFICATION:a hereby declare that the contents of this consignment are fully and accurately described above by the proper shippingname and are <br /> t � « ' <br /> marked and Iabeied/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.if export shipment and I ss the pa <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowiedgmnte of Consl an e classified;packaged, <br /> I certify that the waste minimization statement Identified in 40 CFR 262.27(a)(if I am a large quantity Primaty <br /> Gene tor'slOfferors.Printed.... .. Na 9 q ry generator or(b)(if l am a small quantity generator)is true. <br /> Sign ure <br /> f Month Day Year <br /> J 16. nternationa'Ship its <br /> ❑Import to U.S. ❑Export of entry/exit: <br /> Transporter signature(for exports only): from U.S. Po <br /> 17.TransporterAcknowledgment of Receipt of Materials Date leaving U.S,: <br /> Transporter 1 Print /Typed Name ' <br /> Signature <br /> / Month *—Year <br /> Transpo do ed1T e Name j r, <br /> Signature <br /> Y <br /> 18.Discrepancy r, Month Day ar <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ' <br /> ❑Residue ❑Partial Rejection <br /> ❑Full Refection <br /> 18b.Alternate Facility(or Generator) Manifest Reference Number: a.r <br /> .S.EPA ID Number <br /> Facility's Phone; <br /> 18c.Signature 0-01flate Facility(or(ienerator) <br /> Month pay Year <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 3. 4. <br /> 0.Designated Facility Owner or Operator.Certificaiton of receipt of hazardous materials covered by the manifest except as note "Item 18a <br /> rinted/Typed Name r' <br /> Signature. <br /> Month Day Year <br /> i <br /> xm 8700-22(Rev Previous editions are obi ete. t Cy <br /> DESIGN®TPn earn�T" <br />