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Please nl ter e. Form designed far usa on able 12 ��LA�mN"�� <br /> IM NP ( � ( -pbeh)lypex+iter. Foola 2 9 <br /> UNIFORM HAZARDOUS 1 1.GeIlPrzla ID Number 2pagelof 3Enargency Rasponsi Phme 4.mannii Treckirtg Number <br /> WASTE MANIFEST .. . . • 'r JJK <br /> 5.Gemea3tpys Name and Mahn Address - Generators SkeAddress(tl®Ilam!than noting address) ; <br /> (aneaaafs Phone: " <br /> 6.Trnspaler 1 Cmpary Name, U S EPA ID Number t <br /> 7.7aneporla2 Campary Nemo <br /> U.S.FPAID Number <br /> Y <br /> 8.Deagnaled Fadity NamealSi@Addness U.S.EPAID Number <br /> Fad' s Phaa: <br /> gar 96.U.5.DOTDesaipthn(noludag Proper Shipping Name,Hazard Gass,ID Number, 70.Camvners 11.Tdal 12.UnN ! <br /> HM and Paddng GmuDfdany)) No. Type Quantity Wt/Mol. 13.Waste Coda <br /> 1. <br /> O0i <br /> r <br /> i 2 <br /> W <br /> 3. I <br /> 4. <br /> i <br /> 14.Special Handing nsbudms andPadnpnal Information <br /> i <br /> 15. GENERATDR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment am fuly and 2ccuret4y described abuse by the proper shipping name,and are classified,padaged, } <br /> marked arid labeled/placarded,and are in alms"N propermndition fa transportaaroning to applicable nlameffican d nagonal gmemmental regulations.if egret shipment and lam the Primary <br /> Exparnr,I csmfy that the contents of Bis comigranentconfam to the tamp of the attached EFAAnkndvdedgment of Consent. <br /> I partly that the waste mimmtrstlon salamenl identl8ell in 40 CFR 262.27(6)(if I am a largo quanblygenerabr)or(b)(if I am a sinal quantity generator)is nue. <br /> Gem W*Oawor'e PdnteNryped Name Signs ure Month Day Yea { <br /> —1116,Informational me <br /> Shipmate <br /> i ❑IMP to US. ❑Export from u.s. Pm of entry/exit <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> rk: 17.Transporler Acknowledgment of Receipt of Materials <br /> Transm em 1 Pdnleo(Typed Name Signature - .Month Day Vear <br /> IL <br /> Transporter 2 Pmadrryped Nene signMare Month Day Vear ! <br /> 18.Discrepancy <br /> f <br /> 18a.Discrepancy Indication Space <br /> El Causality ❑Type ❑Residue El Partial Rejection ❑Ful,Re)ecoon <br /> Manifest Reference Number j <br /> 18b.AMmaa Faciily(dr Generear) U.S.EPA ID Number <br /> U 1 <br /> LL Failys Phone: <br /> raW 18c Signature ofAltemate Facilty(a Generator) Monty Oa/ Year, S <br /> 2 <br /> 18.H®rdous Waste Report Management Method Codes(i.e.,codes for hazardous waste realm al;disposal,and recycling syarsrel <br /> 1. 2. 3. 4. <br /> 1 <br /> 20.Designated Faddy Owner or OperaNr Cerh7ca ion of receipt of hasadus materials covered by the manifest ex Wpar nod in Item 1 B <br /> PrinteaTyped Name Signature Month Day Year <br /> I <br /> EPA Form 8700-22(Rev.3.05) Previous editaa are obsolete. 3ENERATOR'S INITIAL COPY <br />