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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) ,i.1'*:. Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 1.Generator ID Number _ 2.Page 1 of 3 cy Response Phone 4.Manifest Tracking NumCber ^� �/(� <br /> WASTE MANIFEST f.!'{;1�.'3 411, -:":1 1 -,'inA 1'f_IA Q iJ J l7 U�'J SK, <br /> V42 <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> Generator's Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 5Al"ETY Kt_EFP; aY`,i'iE.IVIS 1 1:N!', 7Xc 10k?1r:1 Q <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated facility Name and Site Address _ <br /> 1�t�i'4: (Y`-h(I_i:F_;y 15- C IIL_iFi]i?P;[A, 1P1C: U.S.EPA ID Number <br /> 588'1 SMITH AVCS, <br /> NEWARK f'A 3456a0 <br /> 510--7'3`i._4:ia?0 � <br /> Faciliys Phone: --- .AC 7'hhtJF, <br /> 9a 9b.US.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if ani13.Waste Codes <br /> No. Type Quantity Wt.Nol. <br /> of <br /> 1 JI AR liil'o 4 ,-tic WA- L t l/j I i TT � 1: :3 <br /> 3 S_" <br /> Z 2. <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Adulterer Information <br /> TS=i;:'.'r;:r '_50474_? C€1479`.;8 ='411r'I. 3t"i <br /> D4 HP EMFRGEl" i 41-800-462-17SO (SY, r' TIM <br /> MfITL4 OC o .cAT_r r r;: ! Ti t'_(` "p r p• .• _ <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: thereby declare that the contents of this an gnmentarefullyandaccuratld,- scnbedabove by the propershipping 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 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 wasteminimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generamesl0fferors PrintedlrypedName Signature- Month Day Year <br /> 16.International Shipments _ - <br /> Z ❑Import to U.S. El Export from U.S. Port of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.TranspoderAcknowledgment of Receipt of Materials <br /> Transporter Pdntedfryped Name / Signature Month Day Year <br /> O A� <br /> Z Transporter rinted/i ed Name ,Y•'T J <br /> Q P YP 1 Signature Month Day Year <br /> K <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> f <br /> Manifest Reference Number: <br /> F 181b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> w18c.Signature of Alternate Facility for Generator) <br /> F Month Day Year <br /> Z <br /> Z <br /> LD <br /> 19,Hazardous Waste Repel Management Method Codes lie.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. ( I ' 2. 3. 4. <br /> ( <br /> 20.Designated Facility Owner or„Opardtor:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PdntedfT=d Name Signature - Month Day Year <br /> till <br /> EPA Form 8700-22(Rev.3-OS) Previeus Itionsareobs0le}e. DESIGNATED FACILITY TO GENERATOR <br /> !.11, J <br /> rJ • <br />