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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> FUNIFORMAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> ANIFESTSKS <br /> Name and Mailing Address Generalor's Site Address(if different than mailing address) <br /> Generators Phone: <br /> 6.Transporter 1 Company Na a U.S.EPA ID Number <br /> P P Y � <br /> 7.Transporter 2 Company Name U.S EPA ID Number <br /> c 8.Designated Facility Name and Site Address .. ,, I l il. U.S.EPA ID Number <br /> I Facility's Phone: <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity WL/Vol. <br /> 1. <br /> O fll::i�.(?tl. `r1 F.':. _. 3L1t_r; Off <br /> w <br /> vzy- <br /> z 2. <br /> w <br /> R! 1 P �' I �l VP ( <br /> 3. L= v It U t:j i=, J <br /> SEP 1 7 2'J`•4 1 <br /> 4. <br /> By <br /> 14.Special Handling Instructors and Additional Information c,. a /c,,,;w l r ;3 R,-t•_j _„;`„ - f A \ <br /> �?=;ti E11LF.GLNI;;=�i:iG-%!b�-;i[1t7=�'e�..: l{i'(F ;•-S_F.-:►=Gr.ter'w r}?•t:.a a:F.�i•� c`,c�-y'�•�b'aF�:-qtr Ci.�i,,-e: -_, •�• _. <br /> - � i i -� ' 7r.l A�hnr'1:P_ '�•l 4fi!� �e• ,,1i1 - _'7 i;t.l i'.!� cif r1� �.7[i tld�i l'.f'%ynti�`i n1..�Fr�.. -,tL =.e�,~,: <br /> 15. GENERATOR'SIOFFEROR'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 EPAAcknowledgmenl of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(N I am a large quantity generator)or(b)(If I am a small quantity generator)is true. <br /> Generator Offerors Printed/Typed Iia a Signature i Month Day Year <br /> 16.International Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of entrylexit <br /> z Transporter signature(for exports only): Date leaving U.S,: <br /> W 17_TransportenAeknowledgmentofReceiptofMaterials <br /> oTre�spo er 1 Printed/Typed�Name Signa)nre•^ Mfpcn�th Da Year <br /> C- � �'� WLU'^C r �-' ! JFK <br /> U) f <br /> a Transpo or ted/Typed Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residuej <br /> ❑Partial Rejaction El Full Re action <br /> Manifest Reference Number. <br /> 18b.Altemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> r rsw _ <br /> LL FaaiVs Phone:.. - <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> z ' <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> q. 2. 3. 4. 'd <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except aspded In Item 18a <br /> p �y7y�Name Signature- r i Moov, Pay Year <br /> l-h / / F <br /> ,.r( �lo. �!• _i. r.' �'i .�,•° ti'�_�{ 4'9� 1,-J I� k <br /> EPA Form 8700-22(Rev.3-005)Previous editions are obsolete. DESIGNATED FACILIT'I( 0 GENLhAk j11 <br />