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Please prior or type. Form Approved.DMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 GenOatOr I Number' 2.Page 1 of .3.Emergency Response Phone 4.Manifest Tracking Humber <br /> WASTE MANIFEST 81-10-424 u rs1F .5 915 3 3 JJ K <br /> 5.Generators Name and Mailing Address �• GeDeraaWs&o Address{td than mailing address) <br /> }'t�]'at 31 mats iwt�I f�141�}iA C:ti } <br /> 14[Tr7aCi?i3 s l� .nP yHi i!;F=. i P,�Flst]tl i,A 1451'41 S t;A <br /> Generator's Phone: 2M.-621-4 <br /> .. <br /> 6.Transporter i Company Hama U.S.EPA IA Number <br /> -y s." a JA 3'4aNN <br /> 7.Transpoiier 2 Company Name U.S.EPA ED Number <br /> B.Designated Fadfity Name and Site Address [7.5.EPA ID Number <br /> 7:;-r.r: +..; � .C'•' k''V:�itail <br /> Facgily's Phone: <br /> 9a 9b.U.S.DDT Nsscriptiart.(rndud'mg Proper SKPOng Name.Hazard Gass Id Number, 10.Coniainero 11.Total t2.llrtit <br /> HM and Packing Group[f any)) No. Type Quantity wuvoi. 13.'Waste Codes <br /> 1. <br /> f'r�..`d'ziiu��r*.-F *'7 T7f:FF�'i�r,y�:F,vFf 1'11 i f s J�`►.• �r.r '..s <br /> Zr 2. <br /> LU <br /> 3. <br /> 4 <br /> '4.Special.HandlirTg Instructions and Addilional InfamtaWn <br /> 15, GEN ERATOR'SMFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment ere fully and accurately described above by the proper shipping name,and are classified;packaged;. <br /> marked and labaledlpOcarded,and are In alt respects in proper condition for transport according to applicable international and natlonal.govemmental regulations.if export shipment and I am the Prim* <br /> Exporter,I certify that the oontents of this consignment conform to the terms of the attached EPA Acknorwiedgment of Consent <br /> T certify that the waste minimization statement identified in 40 CFR 282-27(a)(91 am a large quantity generator or(b)(If i am a small quantify generator)is true. <br /> Ganerator'sJOf flow PdntedTTyped Name S'nature - - <br /> `g ----��.. Mpnth .Day Year <br /> -,I 15.International Shipments - - <br /> r ❑I.mport to U.S. ❑Export from U.S. Port of entrylexlt: <br /> ? Transporter signature(for exports only): Date leaving V$. . <br /> W 17.Transporter Admcvwledgmentof�e pt ofMaterlah <br /> Transporter 1 pdntedfTyped Name [ 7 Signature {. , Month Day Year <br /> r� <br /> 2E Transporter 2 Printedlryped Name SignaSwe g Mom Day Yaw <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ 0"aty ❑Type ❑ ❑Partial Rejection ❑Full Rejec m <br /> Manifest Reference Number. <br /> i8b.Alternate Facility(or Generator) f1.8.PPA ID Number <br /> t3 <br /> L Facility's Phone: <br /> Lu 180.Signature of Altemate Facility(or Generator) <br /> Month Day Year <br /> a <br /> a <br /> en <br /> 8.Hazardous Waste Report Management Method Codes(Le.,codes for hazardous waste treatment,disposal•and recycling sysmrrrs) <br /> r r -.,r-. 2. 3. 4. <br /> i t �_- <br /> 21 Desigriato4 Facility Owner or Operator.Ceffi4on of receipt of hazardous materials covered by the manifest except asmaGad in Item 18a <br /> Prnted'ype t"— { _ Signature`-_ -r <br /> 4 ih i .I,��I'D ra,`'_7 r ... f.-_- �-- i - Day rear <br /> EPA Form 8700.22(Rev.1217) Previous editions are obsolete. TRANSPORTER O <br />