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+rd . <br /> Please print or .(Form designed for use on elite(12-pitch)typewri ��3 <br /> ter.) Form Approv94&ODxi <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 13.Emergency Response Phone 4.Manliest Tracking Number <br /> WASTE MANIFEST c��a���l 3 900--Y-9 0 0 9 5 6 2 7 3 0 FLE <br /> 5.Generators Name and Mailing Address w — 1 Generators Site Address(if different than mailing address) <br /> tY�l3�+►�(�T A�� �V�S� , <br /> Qy <br /> .Zr <br /> ►r wr t t A- 9 S'31 0.YKL <br /> Generators Phone: 'A — 3"1&—'13 I3 <br /> Y ame U.S.EPA ID Number <br /> -4 Uv,tV j M -wAVL v � 1 AJC. , N&v4 0 C8 3 as.3-a <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Fadity Name and Site Address p U.S.EPA ID Number <br /> Q q Kers i�ck3�'C oris <br /> b2.D �% Qt.,�.c�.s-�• C.��n� ��.V-a.��.�►cs- gyp►- X333 �'l <br /> CAL- O'oo��S3s�, <br /> Facd' s Phone: to 61— — s' <br /> ga 9b.U.S.DCT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group Cd any)) 13.Waste Codes <br /> No. Type Quantity WtJVoI. <br /> o N ori Q��Aa- +x*L►4r�1D o�S �...�oa�c, f7�� 3 <br /> Z 2. <br /> LU <br /> to <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 1► p ';L �3-oa <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the conten of this consignment are fully and accurately described above by the proper sNppN name,and are classified,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If expo t shipment and I am the Primary <br /> Exporter,I certify that the contents of this oonsigrunent conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(d I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> sPrinted/Typed Name Signature Month Day ear <br /> mac 1 '- I <br /> 16.International Shipments <br /> P- ❑Import to U.S. ❑Export from U rt of entry/exit <br /> T nature fore only): Date leav U.S.: <br /> 17.Transporter Admowledgnant of Receipt of Materials <br /> Trio 1 PdntedlTyped Month Day Year <br /> 0 Ll,e, <br /> Q Transporter 2 Printedfryped Name Signature Month Day ear <br /> 05 <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space �Ouantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> AtUal Q44 1/0 r <br /> S Manifest Reference Number <br /> 1-1 18"A temafe Facility( nerator) U.S.EPA ID Number <br /> U <br /> a <br /> LL <br /> FacWsPh <br /> 18c.Signatrae of Altemate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> V519,Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and reading systems) <br /> G 1. <br /> 20.Designated Fadity Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Tim—Typed N— Signatu Month Day Year <br /> D 1 <br /> EPA Form 8700-22(Rev. 5) Previous editions are obsolete. 1011 Of I NATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />