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Wa25505(.)(:R) <br /> a�vXes�s <br /> Sr)oepa��e <br /> 0039 <br /> roved.OMB No.2050 l ��2 atia�ao <br /> ForrnAPP <br /> lease print or type, 4.ManifestTracking Number Q ^ j J K 01" G0,65 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 0259 <br /> 3 4$SCJt `�`a�a�as <br /> WASTE MANIFEST L 0"31 S07 � $dd.$1�.,��� d <br /> 5.Generator's Name and Mailing Address address) �0 <br /> Generator's Site Address than �"g � <br /> hu#ant I14UM 5tnctidt�n,PM3 <br /> u <br /> Generator's Phone: ANOfl07t10 7;3 7 <br /> U.S. <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> V Fonda lawl4ramw SWIM <br /> 7.Transporter 2 Company Name iRYi <br /> U.S.EPA ID Number <br /> I <br /> 8.Designated Facility Name and Site Address <br />/ Crra*Y&L 0wW <br /> 100 W I7th 5L <br /> LWM t 1,to 9M1 11.Total 12.Unit 13,Waste Codes <br /> Facility's PHhTne: 10.Containers quantity Wt.NOI. <br /> 9b.U. . Description(including Proper Shipping Name,Hazard Class,ID Number, No Type P $ � <br /> 9r). <br /> HM and PackSDOT Descron PP 9 <br /> n I Group(d any)) 0A lll b ID D <br /> 4 <br /> LJ <br /> h 2 <br />'J L <br /> 4, <br />\ 1:.Special Handling InsWcfions and Additional Information .#'71 <br /> 1 VIER;0225# dl A4 4864949 <br /> h Q^� r S hh �orLt r <br /> >v <br />�y c <br /> respects in proper condition for transport according io applicable international and national governmental regulations.If export shipment and I am the Primary <br /> 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 labelediplacarded,and are in all rep P <br /> s Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. Month Day Year <br /> O� certify that the waste minimization on statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I/am a small quant ty generator)is true. L <br /> a\� Generatot'slOfferofs Prinledrryped Name <br /> ❑Expott from U.S. port of entry/exit: <br /> meq16.International Shipments LJ Import to U.S. Date leaving U.S.: <br /> '— Transporter signature(for exports only): <br /> 17.TransporterAcknowledgmentof Receiptof Materials Signature Month Day Year <br /> TraJ&�B�a&x <br /> nledflyped Name 1 , f <br /> �O Signature Month Day Year <br /> 0 Transporter 2 Printed/Typed Name <br /> C <br /> 18,Discrepancy <br /> 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> t Manifest Reference Number. <br /> 18b.Altemate Facility(or Generator) U.S.EPA ID Number <br /> P C Facility's Phone: <br /> � 18c.Signature ofAltemate Facility(or Generator) Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste tment,disposal,and re-cy*9 systems) <br /> tr <br /> 3- 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials coveredfianifest except as noted in Item 18a <br /> Printed/Typed Name Signature Month pay Year <br /> 11 .n <br /> 'A Form 8700-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e•MANIFEST SYSTEM <br /> pa <br />