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Form Approved.OMB No.2050-0039 <br /> •p :< e'=.:' U —:e' 2 Pzoe'o` 3 EmercenT Response Phone <br /> a,Manifest Tracking Number <br /> UNI.ORM HAZARDOUS <br /> WASTE MANIFEST J J K <br /> a;c s --!?':'.'a::n-Address Generators Site Address(if different than mailing address) <br /> \a—? U.S.EPA ID Number <br /> i <br /> _ U.S.EPA ID Number <br /> - _ <br /> -- •-_ -- ?—e a-:S e ter_ess :i S._PA ID Number <br /> - _ -- - - -- - -„ass-. Waste Codes <br /> 10.Containers 11 Total 12 Unit 13 <br /> No. Type Quantity WLNol, <br /> ofi <br /> O� <br /> Q' I <br /> LU <br /> wj <br /> Z _ <br /> LU, <br /> i <br /> I <br /> 1 <br /> i <br /> j <br /> I <br /> i <br /> s <br /> i <br /> ;_\_.-- OR c CrccRDR S CER'IFiCAnON: a a: :e=a-a: a::e xr:e s[`t ;:c-;_re-:arz a-c accurately described above by the proper shipping name,and are classified,packaged, <br /> na�onal cove nmental regulations.If export shipment and I amth Primary <br /> _ -- <br /> 2;2.2'e { a- a ar:e:cave gen=era;:,ar,bj.rf I am a small ouantity generator)is true. <br /> Month Day Year <br /> Ex:or ran J.S. ?ort efenlry.er:: <br /> Date leaving U.S.: <br /> Ohlonth Day Year <br /> CL <br /> C/3 _ _ <br /> Q _ =- -_ _ Scna�re Month Day Year <br /> " "°""a a e _I QuanGv Type ❑Residue ❑Partial Re ection <br /> 1 ❑Full Rejection <br /> Manifest Reference Number. <br /> 85.A ternate,Fa,:'ir::c•Zener:o•' U.S.EPA ID Number <br /> J <br /> U <br /> ►ai Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> 19.Hazardous Waste Report Management Method Cod (.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> p 1 2 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification f receipt of hazardous materials covered byft manifest except as noted in item 18a <br /> Pdn . yped Name Signature <br /> c , Month Day Year <br /> EPA Form 870022(Rev.3 05) Previous editions are tisoiete, <br /> TRANSPORTER'S COPY <br /> 990/60011 OUI SOAS AKH AfIOKHM 66fir£8VVL0LT XVA 9T:9T TTOZ/ZZ/80 <br />