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Please print or type. (Form designed for use on elite ( 12-pitch) typewriter.) Form Approved, OMB No. 2050-0039 <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2. Page 1 of 3. Emergency Response Phone 14. Manifest Tracking Number <br /> WASTE MANIFEST it � to i <br /> . 1 <br /> FLE <br /> 5, Generator's Name and Mailing Address Generators Site Address (if different than mailing address) <br /> 170;? JM.c�; ( ¢ >1 ag I d. , <br /> tt-Witte} CYAd VMQ16 <br /> Generators Phone: <br /> 6. Transporter 1 Company Name � � � n r U.S. EPA ID Number <br /> L. : n ,t ¢ R ( i t } p <br /> { <br /> t t + > tj <br /> 7, Transporter 2 Company Name / & U .S. EPA ID Number <br /> F IF <br /> It <br /> I . <br /> 8: Designated Facility Name and Site Address U.S. EPA ID Number <br /> rd"FbInk,00 Trwvft, LLC ENVIRONMENTAL <br /> Fkwd <br /> HEALTH DEPIVITMENT <br /> Facility's Phone: <br /> 9a 19b U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10.. Containers . 11 . Total 12. UniC 13, Waste Godes <br /> HM and Packing Group (if any)) No. , Type Quantity Wt.NbI, <br /> 0 14 A U WASTE .MUD (OILS' AT <br /> Tr <br /> FIF <br /> Z 2. <br /> W <br /> LU I IF <br /> 31 IF <br /> 4 4• <br /> IF <br /> 14. Special Handling Instructions and Additional Information <br /> t NWher WSW DWAMW <br /> IF <br /> AGT47VILF) <br /> 15: GENERATOR'S/OFFEROR'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 labeled/placarded; 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 Primary <br /> Exporter, I certify that th orients of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> J, certify thIF Iat thh aste mi mlz.Mion statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or,(b)�fifyam ,%mall quantity generator) is true. <br /> Gene ator s Printe ame inatur Monthar <br /> wi Tr . <br /> FI <br /> 16;-Intemational ipments <br /> F , ❑ Import to U.S. ❑ Export from ll.S. i Port entry/exit: <br /> NIPPONz Transporter signature for exports only): i Date leaving U.S.: <br /> W 17;Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printedrryped Name Signature " Month Day Year <br /> } ? j, y �y /� �/, <br /> NC ' �L 7...r 1 '`�"� f f - e. J { / ' • ! l' rl � rvy J �`{� I - <br /> Q Transporter 2 Printed/Typed Name Signature Month Day Year <br /> H <br /> 18, Discrepancy <br /> 18a. Discrepancy Indication Space Quantity 11 Type El Residue ❑ Partial Rejection ❑ Full Rejection <br /> t ' <br /> Manifest Reference Number: <br /> 18b. Alternate Facility (or Generator) U.S. EPAraD;Numberi <br /> J i <br /> W Facility's Phone: <br /> w 18c. Signature of Alternate Facility (or Generator) Month Day Year <br /> aIF <br /> Z IF <br /> 19, Hazardous Waste Rep P'Wnagement Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> W t 12, 3, 4. <br /> D <br /> ff (f <br /> 20. Desigqafed Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except asnoted;in Item 18a <br /> Printed(ryped Name { " Signature r i' Month Day Year <br /> KI It, <br /> r <br /> F` <br /> IF <br /> 40 r > t D1rt <br /> EPA Form 8700-22 (Rev. 3-05) Previous editions'are obsolete. DESIGNATED FACILITY TO GENERATOR <br />