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C7 <br />n <br />Form Aooroved. OMB No. 2050-0039 <br />lease <br />pnm or type. trorm aesrgneu <br />UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />wr ube vn enre i -P--) w ---i <br />1 G eW r ID Number <br />/! <br />F 1 I t > c: 6 <br />2. Page i of <br />3. Emergency Response Phone <br />�� - L� .^,1 <br />4. Manifest Tracking Number <br />0 0 0 3 5 8 7 8 6 FLE <br />5. Ggnerators Name and Mailing Addre i Generators Site Address (if different than mailing address) , <br />. <br />�l E`k w, ldf ; 1 t�(� L1� 4' I r�iZClpli tfi W , " <br />. its: t Mb/C1 %f};jff ia0-v- <br />f ` <br />U rrl <br />..ice � �� <br />6. Transporter 1 Company Name. U.S. EPA ID Number <br />6. <br />-= i! f <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />6.signated Facility Name apd Site Address. L� U.S. EPA ID Number <br />�I>vGlr`� <br />fnta^ (C/ I ISL <br />^L <br />/'F� <br />F,r.T, �s'PhbneraCj C) ) t-) !L (� .{ .� <br />ga <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12, Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />0 <br />w <br />W <br />2. F Pu(nInd 1L 5c �C�r.��:at?Ic,� <br />t <br />3. -- <br />De- (CfCicr_.JF tr,Ufrj,F-ILv�ii?u�_;!`.�iGxlC <br />4.f0�vrr�o ��e,R �t���Ju.�,i7 ,���'(t`_:(:�,'=c. <br />Kj <br />i <br />14. Special Handling Instructions Addifioh information �+ <br />'t16 -l-4 <br />LA X c <br />J <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: 1 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 EPA Acknowledgment of Consent. <br />1 certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />Generators/Offerors Printed(Typed Name igna ' 1Month ay Year <br />-� <br />Z <br />16. International Shipments <br />❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: <br />Transporter signature for exports only): Date leaving U.S.: <br />w <br />17. Transporter Acknowledgment of Receipt of Materials <br />O <br />Transporter t PrintedNae Signature nth Day Year <br />° <br />C f/ - 10j - <br />Transporter 2 Printed/Typed Name t SignAre V Month Day Year <br />e- <br />18. Discrepancy <br />18a. Discrepancy Indication Space <br />Quantity ❑Type Residue L <br />Manifest Reference Number: T�S b i <br />18b. <br />18b. Alternate Facility (or Generator) <br />_J <br />U <br />rb't f -f <br />� b5C3 1170` VJ4 <br />Q <br />w <br />Facility's Phone: v <br />18c. Signature of Alternate Facility (or Generator) (h 2'ja Year <br />[1[bt. <br />19. Hazardous Waste Repot Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />W <br />0 <br />1. 2.3. a. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printed/Typed Name Signature Month Day Year <br />EPA Form 8IUU-22 (Rev. 3-Ub) rrevlous eoltlons are oosolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />