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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.Pagelof 3.Emergenq Response Phone 4.Maaniifeest Tracking Number Cis <br /> WASTE MANIFEST 000'- VES <br /> 5.Generators Name and Mailing Address ,w^y �I��� <br /> Generators Site Address(ifdiRerera than mailing address) <br /> Genemtors Phone. :Jb _. ■ ■ <br /> tAj <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 0 7 2015 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address UCAITY - --- TAdC�IT U.S.EPA ID Number <br /> Fill liys Phone: <br /> ga 9b.U S.DOT Description(including Proper Shipping Name,Hazard Clan ID Number 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group if any)) No. Type Quantity till <br /> 1_ <br /> K <br /> QO <br /> C <br /> Z 2. <br /> our <br /> O <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Intonation <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of th s consignment are fully and accumtely 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 ac ounding to applicable international and national governmental regulations.If export shipment and 1 am the Primary <br /> Exporter,I ceNfy that the contents of this consignment conlotm to the terms of the adac ad EPAAcknoWedgmenl of Consent. <br /> I ceRity that the waste minimisation statement identified in 40 CFR 261(g l am a Is ge quantity generator)or ho(if I am a smell quantity generator)is true. <br /> Generators/OSeror',s Printed/Typed Name Signature -7 Month Day Year <br /> L <br /> J 16.International Shipments <br /> ❑Import to U.S. Export from U.S. POR of enbylexit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Malenals <br /> K Transporter 1 Printed/Typed Name Signature Month Day Year <br /> CIL <br /> QTransporter PrimediTyped Name Signature Month_ Day Year <br /> t18.Discrepancy <br /> 18a.Discrepancy Indication Spars ElQuantity ❑Type ❑Residue ❑PaRlal Rejection ❑Full Rejection <br /> Manifest Reference Number <br /> 18b.Alternate Facility IT Generator) U.S.EPA ID Number <br /> J <br /> U <br /> rai Facility's Phone: <br /> 18c.Signature of Altemate Facility(or Generator) Monty Day Year <br /> Q <br /> Z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste in atment,disposal.and recycling systems) <br /> 1. 2, 3. 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by Na manifest except as noted in Item 18a <br /> 1 Printedffyped Name SignaWra Monty Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />