DocuSign Envelope ID:813A5323-29B6-4DDD-A2B8-22B7F4A4A68C •
<br /> r ,
<br /> •
<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) - ,
<br /> Cta �rt r y u.,:-.,,,,v,,,,, fir({.c c �`: �,) k5 (L ," 41 ..ss c�Tf
<br /> Oeneralars Phone: ,.-1,1q trJ { U.S EPA ID Number
<br /> 6.Transporter f CompanyName .
<br /> I L
<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 • .
<br /> ICU 0 t\ti L, �c
<br /> •
<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. _ •
<br /> } {
<br /> a d•,4-ei(7 11` r"C ast,;7 )6k .O i -ti- "tom _�' 13. )` .
<br /> F •
<br /> N`,:):, 6 `'Y �t,
<br /> " , \ - —
<br /> % ‘.k 0. , 11.x. 7� ` IiII
<br /> j 4 4.- . �( .,3 :i.'•.s, (16,t? 1::,,:F..:+t;O.y . �Ui Atli , �ytittt� 1 ,. ,,..., .C___,F,„.. ,. ..R -r;-- mil _____'"'. - - -,-CIC5k VI— clur5A.J. ' - .
<br /> •
<br /> •
<br /> ( 4.Sp=;al Handling InsGUdlonsand Add itional lnfonnaticri • 5 ) k---0,6/6/55
<br /> a'
<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
<br /> —
<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
<br /> las f
<br /> can
<br /> Trans
<br /> I ` ( Øf7 I j` }g v n ...
<br /> a Year
<br /> Z Transporter Printed/Typed Name Sign in y
<br /> j-
<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 .
<br /> 3
<br /> U I
<br /> Facility's Phone:
<br /> M 180.Signature of Alternate Facility(or Generator) --,-.., Month Day • Year •
<br /> a I
<br /> =
<br /> CD
<br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment.disposal,and recycling systems) -
<br /> 3, 4.
<br /> cWi
<br /> 1. '
<br /> I ftlit~�i! • t d :.114. 1 •gLt --
<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
<br /> S o .1- t..: 1}1. I��~' s� ~_�_�__ I.. .J t.1 t:
<br /> EPA Form 8700-22'(Rew 3-05)Previous edf ons are obsolete. - ' ' EiyeSTUN]ATED FACILITY TO GENERATOR
<br /> k,w .
<br /> .
<br />
|