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Please print or type.(Form designed for use on elite(i 2-pitch)typewriter.) <br /> �'FDo'n�'2d.qOB No.2050.0039 <br /> 1.Generator lD Number 72.Page 1 of 3.Emergency Response Phone an Tracking Number <br /> UNIFORM HAZARDOUS. 009889518 JJ <br /> WASTE MANIFEST u U ij 1 G i;j a- ' <br /> Generato <br /> 5.Generators Name and Mailing Address r s Site Address(if different than mailing address) <br /> Genemtoes Phone: 7 �r=' t <br /> ' `. :. U.S.EPA IQ Number <br /> 6.Transporter t Company Name <br /> ri�'r-t,': : ; t,;f i-v F;•- r ;lls��C C A D 1? 2 3 -7 1I 31 6 <br /> H.� U.S.EPA ID Number <br /> 7.Transporter 2 Company Name <br /> 8.Designated Facility Name and 51teAddress -ENVIRONMENTAL OTAL HEALTH U.S.EPA ID Number <br /> DEPARTMENT <br /> s '75 �11UE <br /> LOS'kt1-1C-E <br /> Facifitys Phone: <br /> go.U.S.DOT Description(including Proper shipping Name,hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> 9a g No. Tye (quantity WtNol. <br /> HM and Padding Group(rf any)) f <br /> _ i t <br /> t_r lv� <br /> LLl I <br /> 3. r <br /> i <br /> 4. —- - - <br /> i <br /> 14.Special Handling instrudons and Aodltional Information <br /> '.C��Y�L�'.:J.�..r`Ir_J: ..fir�'i•Tl':�::I 1 � r4;24 <br /> y Air..• k�'-•.-1y`=.l�ta{ V(//_�F 3.01 _S <br /> ^ <br /> A i r.i`_ ,',t t -�'? �I '^ �f.Fit;;C$�F�OiCr:Tl'!'_t�`t.�i�s*E'`; <br /> 15. GENFR4TOR'SIOFFEROR'S CERTIFICATION: I hereby decla2��aatQ et contents thrt is consrdingignment <br /> are <br /> f uY anndatlon—al and nationalgovemmentalbmo by�regulatioits.ral e proper mnexport shipment andg name,ard am�the Primary d <br /> marked and labeled(plaratded,and are m all respects P oP <br /> Exporter..I certify that the contents of this consignment conform to the terms of the abehed EPAAetmordedgmerd of or Co en a Snlail qua netal0�is We. <br /> I certify 01st the waste minlmizaWn statement identified in 40 CM 2M 7(a)(f I am a large quantity generator} <br /> wW <br /> rs PrinledlTyped Name Sig <br /> 16. '5hip ents Import to U.S. ❑Export from I.J. Port of <br /> PE; <br /> Date isavi U.S <br /> Z Transporter signature(for exports only): <br /> W- 17.TransporterAdmoMedgmentofReceipt ofMaterials M Y <br /> Transporter 1 ypad N ma ✓ Stgna <br /> o <br /> Q-' Sign a Month Day Year <br /> aTransporter dntedffyped Na <br /> 18.Discrepancy <br /> Typy ❑Residue ❑Partial Rejection ❑Full Ra}oction <br /> 16a.Discrepancy Indication Space Quantity <br /> VaflWest Reference Number. <br /> U.S.EPA ID Rumber <br /> 18b.AOemate Facility(or Generator) <br /> ram Fadiltys Phone: Month Day Year <br /> W 1 So.Signature of Alternate Faality(or Generator) <br /> Man Method Godes(i.e,,codes tar hazardous waste treatmart,dsposal,and recycling sYaaMs) <br /> i9.Hazardous Waste eportagement 3 4. <br /> 0 1 2. <br /> 20.Daslgnatcd Fa or opera Certification of receipt of hazard material co by the manifest except 65 Riled n Item 1 � pay Year <br /> Signature <br /> Printed/Typed Name <br /> EPA Form 870Q 22(Rev,3-05) Prewo s editions are obsolete. DESIGNATED FACILITY TO DESTI ATION STATE(IF REQUIRED) <br />