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0 0 6 9 5 3 4 4 5 3 Ks <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDf�r ID Number me" --J- <br /> 2.Page,1 of 3.F hqm., 4.Manifest Tracking Number <br /> .W Rq!poppe P <br /> WASTE MANIFEST 100 45 SKS <br /> 5.Generators Name and Mailing Address GenereWs Site Address(ff different than mailing address) <br /> 7 <br /> Generator's Phone; T <br /> 8. T <br /> Tr" QY-Off U.S.EPA ID Number,� rr <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and She Address '�F U41 FF77 7 U.S.EPA ID Number <br /> 06' l f,A r)r"t <br /> Facility's Phone: <br /> 98. 9b,U.S.DOT Description OncludIng Proper Shipping Name,Huard Class,ID Number, V.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(d any)) No. Type Quantity Wtivol. <br /> 7 r,,p IC j-' -:, <br /> rT <br /> 00i to 7 <br /> UJI <br /> C9 <br /> 3. <br /> 4 <br /> 14.Special Handling Instructions and Additional Information T4 Fl FV G <br /> �31,�.'TV' Crj P.'I, t <br /> cin init izil tutO Oddit 10,11al or: <br /> 15. GENERATORISIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classiW,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to appUcat%e international and national govemmerital regutaboris.If export shipment and I am the Primary <br /> 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 gener;4W)or(b)(ifjpm a small 4 entity genr)is true. <br /> Generato{s/Offeraes PrintedfTyped Name Sig re Month Day YeaF— <br /> /jgsTnL- A—Bo <br /> _j 16,International Shipments Import to U.S. EJE. Port of entry/exit <br /> Transporter signature(tor exports only): P&MX. Date leaving U.S.: <br /> 17 Transporter Acknowledgment of Receipt of Materials <br /> Trnart I Nnte a SiMonth Day Year <br /> 0 <br /> CL 2" sce <br /> 5E Transporter 2 PnrdeVypFd Name Signature Month Day Year <br /> OG <br /> 18.Discrepancy <br /> 18a,Discrepancy Indication SpaceQuantityType 0 Residue El Partial Re**, ❑Full Re),don <br /> 0 <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> Facility's Phone: <br /> 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> 19.Hazardous W—.Itl Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1 2. 3. 4. <br /> 20,Designated Facility Owner or 0 perator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1 Be <br /> Printed Name signature Month 77y Year <br /> QA4WfV I �- A 11 12 1 u <br /> EPA Form 8700-22(q®v_.12-1 Z) Previous editions are obsolele. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />