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Please print or type... Form [}M6 No.Z(15[W039 <br /> Approved. <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of &Emergency Response Phone 4.Manifest Tracking Nwnber <br /> WA3Ttr MANIFEST JJ#t <br /> 5.Generator=s Name and Mal€(ng Ad Generator's 81te Address if <br /> �2=!7 ir�ivlal 444,"�Gsr ray{y {dtffereM than maiNng address} <br /> r.=- <br /> 4,ifS31t~. f fi iy ?!r'fy'fVej?4yrs, <br /> Generators Phe; <br /> 8.Transporter 1 Company Name U.S.EPA ID Number <br /> ilfj[n!}j jZI I <br /> 7-Transporter 2 Company Name <br /> U-S.EPA ID Number <br /> 8,Designated Facility Name and site Address U$,EPA ID Number <br /> p, 1�K31JW. ;?•!13!-9'. <br /> Facill s Phone- <br /> 72-54A <br /> ga. 8b.U.S.DCT DescripWri(Including PmW Shipping New,Hazard Cfass,ID Number. ip.Containers <br /> HM and Pacddng Group(d any)) 11.Total 12.Unit 13.Waste Codes <br /> 1. No. Type Queaty Wt.Noi. <br /> r.::•.a: <br /> W4.,IDA. 14,A7vl4,��kP�? 35r <br /> #..m <br /> LU W/ <br /> 2 <br /> .LU <br /> 3. <br /> 4, <br /> Speaa[Handling Instntctoris and Additlonallnfamiabon <br /> ,, g f.]?°i lrfp"W9r �:�[> ', IJE�rtS' H4��t��rN=r�i'� •- -�ii�asf l�+x }lrRr.-.i�,'14�IIh3t <br /> % <br /> } 7.iY <br /> 15. GENEROkTOWWOFFEROR'S CERTIFICATION;t hereby declare that file contents of IhiS consignment are luily and accurately described above <br /> by the proper shipping name,and are classified,padraged,, <br /> marked and labeledlplacardad,and are in all respects in proper condition for transport according to applkable intematfonalgnd national govammental regulations.If export shlpmentand I am Ore Primary <br /> Exporter,I ogrUty that the contents of this consignment conform to the terms of the attached EPAAcknowfedgment of Ceasent <br /> I certify that the waste minimization stalement Identified in 40 CFR 262.27(a){it I am a large quantity generator)or(b)('dl am a small quantity generator)Is true. <br /> GeneratorstOfferors Prfntedrryped Name Signature Month Day Yew <br /> ,j 18-International Shipments <br /> f^ ❑Import m U.S- ❑Export from U.S. Port of enDylexlt: <br /> K Transporter signature(for exports only); bate leaving U.S.: <br /> W 17.Transporter AckrIowledgment of Receipt of Materials <br /> LU <br /> P— Transporter f Printed7yped N Signature7MMM Day Year <br /> Transporter 2 Prfntedlryped Mame Signature +' , Marr flay Year <br /> a <br /> 18.DIscrepancy <br /> 18a.Discrepancy indication Space ❑ Duanbty []Type ❑Residue ❑Paru.i Reject, ❑Full Rejection <br /> 186.Alternate Faadty(or Generators Manifest Reference Number. U.S.EPA[D Number <br /> V <br /> Fatallty's Phone: <br /> 18c.Signature of Alternate Facility(wGanerator) Month Day Yeer <br /> a <br /> l'+ Hazardous Waste Report Management Method Godes(Le.,codas for hazardoru waste treatment,disposal,and raeycling systems) <br /> 3. 4. <br /> 20,Desigrnated Facility Owner or Operator.Ceffimtion of receipt of hazardous materials covered by the manifest except as nded in item 18a <br /> Prin6ediTyped Name S yam __.. Mont Day <br /> EPA Form 8700-22� ev.12-1 Previous editions are obsolete. r TRANSPORTER COPY <br />