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Please print cre.(Form designed for use on elite(12-pItch)Npevnitar,) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 3.Emergency Response Phone 4.Mar&sl Tracking Numbar <br /> ;n., 12.Page 1.1 7 4 <br /> WASTE MANIFEST Sall A JJK <br /> 5.Generator's Name and Mailing Address Generators SYs s(If different than mailing address) <br /> Generator's Phoni?f <br /> S.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Trani 2 Company Name U.S.EPA ID Number <br /> 8,Designated FactityName and Slt&Addms U.S.EPA ID Number <br /> FaclPhone: <br /> sa. 9b.U.S.DOT Description(Including Proper Shipping Name,Hazard Class,ID Nwnbw. W.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity Wtivol. 13.Waste Codes <br /> --T <br /> Z 2. <br /> LU <br /> 3. <br /> 4. <br /> 14.Special HandlIng Instructions and Additional kiformeffon <br /> P <br /> F. CMFfV-,-, F 17'� <br /> 1H itJ10 kt-- <br /> 15. GENERATOR'SIOFFERCRIS CERTIFICATION:I hereby declare that the contents of this cGns'gnment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> markod and labelediplacarded,and are in all respects in proper condition for transport according to applicable intemational and natIonal governmental regulations.If export shipment and I am the Primary <br /> Exporter,I cordly that the contents of this consignment conform to the terms of the attached EPA Ackroyledgi of Consent <br /> LowtIfy that the waste minimization statement identified in 40 CFR 282.27(a)(ff I am a large quar5ty generator)or(b)(if I am a small quantity generator)Is true. <br /> Generators/Offerors PontedlTyped Name Signature Month Year <br /> —j 16,International Shipments <br /> &- D lo-port to U.S. ❑Export from U.S. Pod of aniry/exit: <br /> z Trarsporte,signature(for exports onift Date leavIng U.S.: <br /> LW V.Transporter Acknowledgment of Reoeipl of Materials <br /> o Li <br /> T ranBporter 1 PrfntediTyped Name Signature 7 M 0�1 <br /> nth Y%r, <br /> tol 9 <br /> ;Z Transporter 2 Pdnted7yped Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space 1:1 Quantity El Type 1-1Residue E!Partial RejecRejection. Full Rejector <br /> Manifest Reference Number: <br /> 1 8b-Alemate Facility(or Generator) U.S.EPA ID N11ri <br /> :3 <br /> 0 <br /> LL. Fadllys.Phone: <br /> Im <br /> LU 18c.Siqmfutra of Aftsmate Facility(or Genera" Month Day Year <br /> 0 <br /> jjj 19.Hazardous Waste Re-port Management Method Codes(Le.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LLJ 1 2. 3. 4. <br /> C3 I 1 1 <br /> 20.Designated Facility Owner or Operator.,Certification of receipt of hazardous materials covered by the manifest except as noted In Item 1 Ba <br /> jTrnFed1Typcd Name I Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />