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p.2 <br /> Please print x tyre.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OM No.2D5]-0J39 <br /> UNIFORM HAZARDOUS 1.Gererator ID Number Y Z Psge 1 of 3.Emergency Response P Mini T g p <br /> po trona 4. feat rjckin N= er 1! <br /> WASTE MANIFEST I.' .� i. ;r ?. 2 r., i '� Jr c322' ��K <br /> t Jv 4J�>,_ r•.w'`1. •t'+.� Y. `f' <br /> 5.Genera .Le alld(dei 7 p tdreSg Generators Site Address(If ddferen!their ma-ang addross) <br /> n...� . � <br /> Generators Pnone: <br /> fi.Transporte[,LGoQipylny Ne _ <br /> U.S.EPA IR Npmhec <br /> NOV <br /> 7.Transporter2^orrpeny Name U.S.VA M dumber <br /> S.Dasgnate�' a I yI �S� BdeAddress ENVIRONIMEKkE i•r1 U.S.EPAID Number <br /> yin I Tu ng:pQRTMFNT <br /> Facility's Phone: <br /> ca 9b.U.S.DDT Description(riclud-xg Proper Shiapi•ig Neme,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> Mand Packng Group(:fent')) No, type Quamty N1Lhbl. 13 'Waste Codes <br /> 1. i,�} .-1'wii f' .tl.: . .. rn•r�.:?'.�� ;,.tri.. ;3rd7.t�wi <br /> x 2. <br /> W <br /> $. <br /> 4. <br /> 14.Special Hanolkg Mucliom and Additional Information <br /> .S'�Z.'r�4+,••r• 1 n••,{s �••;1 r'1" a'•"�::i" r?.�. .... _. •�:=+:Sttt4 .t ,...._. Y'�. ....:. ..... <br /> °.��. .+r A"'i' i)1"1i''y�f•t+�Ef+'.'"aCafli4i u":�I�:iYIV .f�>GtllPFN1=f+C; <br /> 15. GENERATOR'SrOFFEROR'S CERTIFICATION: I hereby declare that the contents of thls consignment are fully and accurately described above by the proper shippNrg name,arca are classified,packaged, <br /> marked anc labeled'piacarded,and are in at respects in p open condition for transport according to applicable international and national governmental regulations.r export shipment and lam the Primary <br /> Exporter,I certify uta:the co'ilents o':his consignment corfiorm to the terms of the attached EPA Acknowledgment of..Cowent. <br /> I candy that the waste minimization statement identif eo in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(1 I em a small quanlity genpralor)is true. <br /> GeneratoeslOfferoris�-interyped Nape 'r Signature Month Day Year <br /> 16.International ShipmerAs w - <br /> z ❑ mport to U.S' ❑Export from U.S• Port of entry/exit: <br /> Trarsporter s gna:ure(nor exports oli,: Date leaverg U.S.: <br /> of 1".TransporlerA:*o Aedgmsnt of Receipt of Materials <br /> Transporter 1 PrirdedTyped Name S�sature « Month Day Year <br /> d .wi'..''. rF� r.l .,v cr�'•�,rs�)'6.J>:�4..,rtr" t �'r• -' `~i �.r�:�,^,r�^...•'`.."-.,'. f�wr� t,.'�"7 .r) <br /> rn ._'..fir 'r , .' _�._. --:r•` ���^'s'�'-s <br /> mnsporter 2 Primedrryped Name 5tgna:rae Month Day Year <br /> 18.Ciscrepancy <br /> 18a.Discrepancy indicatior Space ❑ :)"tiw ❑Type ❑Resi,ue ❑Partial Refection ❑Full Rejeelion <br /> Manifest Reference Number: <br /> 18b.Alternate Fadliry for Generates; U.S.EPA ID Number <br /> J <br /> U <br /> W Fadily's Phone: <br /> w 18c.Stnature ofAltemale Paco lity(or Generator) f kmth Day Yea' <br /> a <br /> z <br /> 19.HazardousWule Repan Manegement Method Codes(i.e..codes nor hazardous waste tnsatmsrt disposal,and reeycfng systems; <br /> O 1. ; ( / 2 3. 4. <br /> J J <br /> 20.Designated Fatiliy Drvner yr Operator:Cerllfkatlon of 1 eoel%Qf hazealau¢mate Is covered by the man tart except as noted in Item 18a <br /> Prirttedllyped Nana ; ! Signature hlortth Day Year <br /> EPA Form 8700-22%Rev,3-05)Prwims editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />