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DocuSign Envelope ID:813A5323-29B6-4DDD-A2B8-22B7F4A4A68C •
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<br /> Please print ortype.•(Form designed for use on elite(12-pitch)typawriter) .. • . - Form Approved,OMB No.2050.0039
<br /> UNiFORm 1�AZARDOUS 1 ��eratoorrjID_NNun�tei--. 1 2.Page I of 3.Emergency Response phone . •4,'ManifoitTracking Number
<br /> t .. - WASTE MANIFEST f�„1""l! 12 ; 1� t r -t' .` ,...q `s'.../i 006321479 JJ K
<br /> . 3.Generator's Name and Meiling/ dress t,' Gea tor'sSileAddress(ifdiferentthanmattingaddress) - ,
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<br /> Oeneralars Phone: ,.-1,1q trJ { U.S EPA ID Number
<br /> 6.Transporter f CompanyName .
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<br /> { c-i'�c t. ";( U.S.EPAIDNomhef• I
<br /> 7 Cfiaasporter2 Wmpaoy Name'
<br /> 8.Daslg d FadRy Name and Site Address U.S.EPAID Number • .
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<br /> Fad!' s Photo: 21 . c 't .1 : � 1...IV C b.7 g )2 li r f a ...
<br /> • 9a. 9b.MS.DOT Descrintion(Including Proper StippIng Name,timid Class,ID NuMber, 10.Containers 11,1 61 12,Unit 13.WasleCodes
<br /> HM and Pack ng Group Veiny)) Ho. Type Quantity Wl1Uol. _ •
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<br /> ( 4.Sp=;al Handling InsGUdlonsand Add itional lnfonnaticri • 5 ) k---0,6/6/55
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<br /> 1 GENERATOISSIGFFERORS CERTIFICATION:113erabydeclare that the contents of this consignment are fully andsccureloly described above by the proper shipping name,and are classllted,packaged, -
<br /> marked and labeled/placarded,and are In all respects In proper condition for trensportaccordlgq to apptcebleintem attend and national govemmentalregulations.Seaport shipment and I am the Pdmary
<br /> • Exports,I earthy that the contents of this consignment cenlormto the lormsof Iheattached EPA Acknowledgment of Canaan!.
<br /> I codify that the waste minlintzallon statement tanned In40CFR 262.27(a)gr I am ilargentratility ge Rotator)or(b)(if I am a small quantityg. rator)Istrue. •
<br /> benerato fe101fdmfs Printed/Typed Name Signature , Month Day Year
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<br /> 6,1n1 me anal Shipments •Import to .S. ❑Export fro m ortofentry. ,
<br /> Transparterslgnature(for esiportsanly): •r'--`•' Dale leaving U.S.: 1 p2,, t,
<br /> ' 1T.Transporter owledgmentofReeelptofMaterials - -• f f/! //
<br /> TranØJ4 /f ntediiyped Name Signature Month Day Year
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<br /> Z Transporter Printed/Typed Name Sign in y
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<br /> 18.Discrepancy . -
<br /> 18a.Discrepancy lndicafon Spoon El Quantity ❑Type El Residue ❑Partial Rejection ❑FulLGoloction
<br /> Manifest Reference Number.
<br /> 18b,Alternate Facility(or Generator) • D.S.EPAID Number .
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<br /> Facility's Phone:
<br /> M 180.Signature of Alternate Facility(or Generator) --,-.., Month Day • Year •
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<br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment.disposal,and recycling systems) -
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<br /> 26,Designated Facility Owner crOperator.'Certification of receipt of hazardous materials covered by the manifest except as noted In Item 18e •
<br /> Printed/TypedName Signature ,rt Month Day Year
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<br /> EPA Form 8700-22'(Rew 3-05)Previous edf ons are obsolete. - ' ' EiyeSTUN]ATED FACILITY TO GENERATOR
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