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' Ploase print or type.(Form designed for use on elite(12 pdch)typewriter) <br /> L Generator ID Number Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS t 3 y 2.Page t of 3 Eme{�eney Response Phone., A Manifest hoc mg Number <br /> WASTE MANIFEST „ FLE <br /> 5.Generators Name and Mailing Address <br /> Generators Site Address In modern than mailing address) <br /> i <br /> 5.: <br /> Generators Phone: <br /> .Transporter f Company Name <br /> U.S.EPA ID Number <br /> EST <br /> 7.Trenspoder2 Company Name - <br /> iki, t t ..re t:? I ..-.: U.S.EPA ID Number <br /> u'. <br /> ::.. <br /> B.OeafgnMai Facility area and Site Address <br /> U.S.EPA ID Numher <br /> Facility's Phone: <br /> so. gb.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers <br /> HM and Packing Group(if any)) 11.Total 12.Unit 13.Waste Codes <br /> I ,. _ No. Type Quantity MMOL <br /> �7 2, i <br /> 3. <br /> i <br /> 4. <br /> i <br /> 1 <br /> a <br /> 14. pecial Handling lnsimdions and Additional Information <br /> Jd <br /> IFl <br /> 16. GENERATOR'S)OFPERORSCnd are <br /> res ctsI ydeclare that the coolants ofiIlls consignment are fully and accurately descrbed above by ins propershipping name,and are dassfied,packaged, <br /> marked and labeledlplacardetl and are m all respects In proper condition fortmnspod according to applirabie international and national governmental regulations.If export shipment and I am the Primary <br /> Exparlec 1 cedify that the contents of this consignment conform to the terms of the attached EPAAcknowletlgment of Consent. <br /> I teddy that the waste mininduf an statement identified in 40 CFR 26227(s)(if I am s largequantity generator) small quanGly generator)is tme. <br /> Generalorsl0ltero s riots ITypeU Name <br /> Igna ure tr - ogl ayear. <br /> i6.International Shipments <br /> ❑Import to U.S. <br /> ns ❑Export from U.S. Pori of entry/exit <br /> Traoder signaluro for exports - <br /> w fl.Transpotl 1r flowledgmenl of Receipt or Materials Date leavin U.S.: <br /> Transporter 1 Prudadfryped Name Igna uta <br /> c. ,' r on ay Year- <br /> Transporter 2 <br /> ear,Trees oner2 entail your ams 1r Signature 3° <br /> Mo <br /> n Day Year <br /> e ra <br /> 18,Discrepancy <br /> 'ISa.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue Partial Rejection 1 El Full Rejection <br /> 186.Alternate Facility(or Generator) Man'rfest Reference Number. <br /> —t U.S.EPAIDNumber - <br /> V <br /> t <br /> °- <br /> Facility's Phone: <br /> Uj 180.Signature ofAllernate Facility(or Generator) <br /> Month Day Year <br /> 19.HazaMous Waste Report Management Method Cotles(i.a.,codesfm hazardous waste treatment,disposal,and recycling systems) <br /> ==Rlfestexceptas <br /> 420.Designatedfacility OwnerorOperelor:Certification ofreceipt of hazardous motedals covertem 180 _ <br /> Prinletllfypetl ams - Signature <br /> i - Month ,Qay',,,Year <br /> EPA Form_1,8700 22(Rev.3,06) pr�vjous editmns era obsolete: '' i ""-' <br /> DESIGNATED S'ACILITYTO GENERATOR <br />