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Please print or type. (Form designed for use on elite <br />FGneratcrs <br />AZARDOUS i. Generator ID Numl <br />ANIFEST 1 ©, <br />Name and Mailing Address <br />G� /Cone: t GJe; <br />6. Transporter 1 Company Name <br />77G <br />0 <br />B. Designated Facility Name and Site Address <br />iT 9 'le •� <br />Facility's Phone: _r j _ �7 CJ <br />9a. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />HM and Packing Group (if any)) ' n <br />0 <br />LU"bXr•c,Sc3ircV; //Z cr, C4A+it.,A",v:`,.C`Oppee" <br />I fy/3rr ; c�^ s �, � � �.�, i� y�re� •N ��� C7, /, Llri3a � s <br />4. <br />Form Approved. OMB No. 2050-0039 <br />3. Emergency Response Phone 14. Manlfest Tracking Number <br />000.751500 JJK <br />3enerators Site Address (if different than mailing address) <br />ID Number <br />10. Containers 11. Total 12, Unit <br />No. I Type Quantity WL/Vol. 13. Waste Codes <br />r'oo� <br />343330- -470 :oppe,z may., �1� •>,v�c % i :3 X iS <br />15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping 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 waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (ffI am a small quantity generator) is true. <br />Gen ors/Offerors Printed/Typed Name Siggiatu Month Day Y <br />1.mati hipments <br />❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: <br />Transporter signature (for exports only): Date leaving U.S.: <br />17. I ransporterAcknowledgment of Receipt of Matenals <br />transporter 1,�rintedlTyped Name I Sign ural Month Day Ye <br />rran h� -- G Til �� G� I �/� r• _.. � .__� —, I`�J I �T I Li <br />r18b. <br />crepancy <br />iscrepancy Indication Space Ij <br />❑ Quantity El Type ❑Residue Partial Rejection ❑Full Rejection <br />t}- ternate Facility (or Generator) Manifest Reference Number: <br />-J U.S. EPA ID Number <br />Q ' <br />- . = Raeillys Phone. ------ - — -- --- — ----- --- .. - - -- - --- <br />w 18c. Signature ofAttemale Facility (or Generator) Month Day Year <br />a <br />z <br />w1.' Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />n t <br />( / ( 2• 3. <br />j `-(- r 4. <br />f <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 188 <br />Prirded/Typed Name <br />SI9 nature� � Month_ Day_ Year <br />1 <br />�C�r-�..•��-z:-tib L/ <br />EPA Form 8700-22 (R -W3--05) Previous editions are -obsolete, _.: DESIGNATED FAMLITIf Tr) np,T1Ai AT,r m iinxm <br />