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1 <br /> P!eav Tint or type (Form designed for use on elite 1, Form Approved OfdB No 2050-0039 <br /> UNIFORM HAZARDOUS 1 Gene,a.' N ' :a t of 3 Emery -_y H _. `>e Phone 4 Manifest Tracking Number <br /> JJK <br /> WASTE MANIFEST <br /> Generators Site Address 1d ddlereni B.r• <br /> Generator's Phare <br /> 6 Tran-eoner 1 Company Name US EPA D Nunbar <br /> ra-ii pc er,Company Name US EWA D Nurr:co r <br /> :+ynatM Fac l-ty Name and Sate Address US EPA ID14 <br /> tv s Phnne i <br /> 9h US DOT Desc npbar I nrluding Proper S vopng Name Hara d Class tD NumM" 11 Total �� 13 yta%*Conus <br /> HM and Packing Group(of any)) Qua" <br /> 1 <br /> crO <br /> t- <br /> Q <br /> uj <br /> w <br /> z <br /> w <br /> O <br /> 13 peck Handling Instruclxxhs and Additional Infor nation <br /> I l'If 'I I't I. ] V(AL 414 930r,NtiERt;1/ 1FA 171 "PRI <br /> 'rFIIF N'1u7 rift lfW4Tf_R nRQ[P>~SSr� <br /> T tirJNE 'APPRuPPeRIE PCR^.,UfIAL PR13FFCTIVC 10JIFMLJIF <br /> 15. GENERATOR S'OFFEROR'S CERTIFICATIO : I hereby declare that the contents of this consgnff*M art,Gip and accurately described above by the props shppmg nitre.and are classified.package. <br /> marked and labeled ptaavded.and are in all in proper cortddAn for transport according 10 appi abb iftimetion it and nal onat governmental regu'aborns 9 export shgment and I am the Pnmary <br /> Exporter.I certify that the contents of this nm ent conform to the terms of the attached EPA Aduvoiledgmdtl of Consent <br /> I certify,that the waste minimization statement m lenbW in 40 CFR 262.27(a)fit I am a large q;anLty generator!or(b)(if I am a small quantity generator)is true <br /> :venerators Oeeror's Printed Typed Name Sgrature Mmes Day Year <br /> 16 Irtematonal Shipments <br /> ❑WVW b VS. ❑Export from U.S Port of entry,'exd. <br /> Transooner s gnature(for exports onlyl: Date leaving U S <br /> w 17.TransponerA19d1o%iedgment of Receipt a( <br /> Transporter 1 PnntedTyped Name sgmake Month Day Yea- <br /> a t / - <br /> z <br /> Transporter 2 PnntedTyped Name Sgna n Month Dar <br /> Q -- <br /> 18 Discrepancy <br /> 18a Discrepancy Indication Space ❑ Ouanl ty Type ❑Residue ❑Parf>a1 Rejection ❑Full Re ec:-r <br /> Mandest Reference Number <br /> v� 1ao Aitemate Facility(or Generator) U.S.EPA 10 Number <br /> J <br /> U <br /> Fac lity's Phone <br /> w 18c.Signature of Attemate Facddy(or Generator) 1lpnth Day 3 <br /> r•- <br /> Q <br /> Z <br /> 19.Hazardous Waste Report Management Method (i e.,codes for hazardous waste treatment.disposal•and recycing systems) <br /> LLJ 0 1 2. 3. -T- <br /> 23 <br /> 23 Des gnated Faulty Owner or Operator.Certrfica on of receipt of hazardous ma!enals covered by Ire man fest except as noted in Item 18a <br /> PrwedTiedName Signature "'_.n Z <br /> EPA Form 8700-22(Rev.3-05) Previous editions re obsolete. GENERATOR'S INITIAL COPY <br /> I <br />