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'lease print or type. (Form designed for use on elite (12-pitch) typewnter.) <br />UNIFORM HAZARDOUS 1 Generator ID Number <br />WASTE MANIFEST (D3 I c103(PS <br />2. Page 1 of 3 Emergency ResponsePhone <br />to q(Vtac) <br />4. Manifest Tracking Number <br />0 0 3 5 3 7 4 7 2 G B F <br />5 Gene;firtVactile and Mailing Addressf, /57.7„,v. Generators Site Address (if different than mailing address <br />3L6 <br />) <br />Li "1____ i /we <br />34 f.q 937/ z, - it r,30-75-/ / --- 04-1_ , <br />tveleGtv e--, lc_ ca0 /1-/ c I. 1 5 Tr.(' k-mot e frit ,5-zy <br />Genera o s Phone: urn- 7 Li - UP, j <br />6 T s o er 1 Company Name <br />OVVI ithylVnYit %--4371e6-5 <br />.64tmber _ , <br />60 1 , 000 qz1 Ve3 7 Transporter 2 Company Name U.S. EPA ID Number <br />)u art Aw% cLe taccitri-L1 §¼ 4W- -1S?tt_ I cAka_ow Lis-L(2z_ <br />8 Designated Facility Name and Site Address U S. EPA ID Number <br />4E5 Z. 1,...) 6_5 A-C-1—rai,1/4.5 c-ce 1—cs,c; l' 4,t <br />(ejsoo v5 IA ;two-Lt 'RS <br />FaciliTYPI'41/4nf.4 *RI I'. i- gets litq CP 00 621111 6 <br />ga <br />HM <br />98 US. DOT Description (including Proper Shipping Name. Hazard Class. ID Number, <br />and Packing Group if any)) <br />10 Containers 11. Total <br />Quantity <br />12 Unit <br />Wt.Nol 13. Waste Codes No. Type <br />1 PO i\ ) ?'C M <br />Cie, Dif 4-ezsdeezirs <br />PI it -e0 MI5 CO/51-r Sult6 <br />5 iivt 3-so f 245 <br />, <br />14 Special Handling Instructions and Additional Information <br />aiir J.-A- 2.zoiw.-?- IA-A4 • 125-e 2. <br />15 GENERATOR'SJOFFEROKS 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 labeleCUplacarded. 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 Pnmary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement identified in 413 CFR 262.27(a) (if lam a large quantity generator) or (b) (ill ... . m. . antity generator) is Ire - <br />Month Gene s ff ors . tediTy ed Name Signature Month Da Year /AkWr I oe liz IL ai <br />16 International Shipments Import to U.S Export from Ll S. Port of entry/exit, <br />Transporter signature for exports only). Date leaving U.S <br />17 Transporter Acknowledgment of Receipt of Materials <br />Tranyorty 1 rintedATyped flame Signature Month Day Year <br />Pk- LAN (15//4611 I 68 1 7-21 72., <br />Transpo • ped Name Month Day Year <br />..),---1 0....—t_12.... L eg I'LL I2 Z- <br />18 Discrepancy <br />18a. Discrepancy Indication Space Quantity 7 Type Residue El Partial Rejection Full Reiection <br />Manifest Reference Number. <br />188. Alternate Facility (or Generator) US EPA ID Number <br />Facility's Phone: <br />18c. Signature of Ntemate Facility (or Generator) Month Day Year <br />19 Hazardous Waste Report Management Method Codes (Le codes for hazardous waste treatment, disposal. and recycling systems) <br />1 2 3 <br />20 Designated Facility Owner or rator Certification of re ipt of hazardous matenals covered by the manifest except as noted in Item 18a <br />Printed/Typed Name <br />VCi Ar <br />Signature Month Day Year <br />I_ <br />Vk Form 8700-22 (Rev. 3-05) Previous editions are obsolete <br />Form Approved. OMB No. 2050-0039 <br />DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED)