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_4 <br /> Please print or type.(Form designed for use an elite(12-pitch)typewriter::. Form Approved.OMB No.2050-0039 <br /> 1.Generator ID Number 2.Page of 3.Emergency Response Phone 14.Manifest Tracking Number <br /> UNIFORM HAZARDOUS !, �P� , .—. " , -� <br /> V JJK <br /> F. <br /> ---W�. TE MANIFEST j t— <br /> S <br /> Generator's Name and(Mailingyftks— Generator's Site Address(if different than mailing acdress) <br /> Generators Phone: <br /> 6.TraRspo a". U.S.EPA Number., <br /> .,E—t (game.. <br /> , <br /> ..0ar i.Cor.npany,K <br /> 7.Transporter 2 Company Name U.S.EPA ID Number is <br /> 9.Desipteff J.S.FPA 10 Nt;mber <br /> tame <br /> 11YRA <br /> Ity,N <br /> 77,1 <br /> Facility's Phone: <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazaro Class,ID Number 10 Conlaine s 11.Total 12.Unit 13 Waste Codes <br /> HM and Packing Group(rf any)) NO Quantity WtNal. <br /> 2 <br /> 0 <br /> ov <br /> 2, <br /> 3. <br /> 4. <br /> 14.Spedqj.Hanoling Instructions and Additional Information <br /> -tmv.-, -JyS A..,- <br /> 15. GENERATOR'SIDIFFEROR'S CERTIFICATION: I hereby declare that tne contents of this emsignmint 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 appfina b a intemat.onal and national governmental regulations.if export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment ccnform to the terms of the attached EPA Acknowledgment of Consent <br /> I certify that the waste minimization statement i denlified in 40 CFR 262.27(a)(if I am a large quantity generator)cr(D)(if IF a small quantity gWerator)is true. <br /> GenerMoes/Offeror's Printer ffypad Name x-. Signature Month Day Year <br /> 76.International Shipments <br /> IL- ❑lmpert to U.S, 11'Export from U.S. Pod of entr exit <br /> Transporter signature(for exports only): Date U.S.: <br /> IX 17.Transporter AcknDwledgmerd of Receipt of Materials <br /> LLJ <br /> Transporter I Printed/Typed Name,�, Signature Month Day Year <br /> 0 <br /> Z Transporter 2 Pfinted[Typed NameMonth Day Year <br /> I J <br /> IQ,Discrepancy <br /> 18a.Discrepancy Indication Space Quan* ❑Type ❑Residue ❑Pedal Rejection ❑Full Rejection <br /> I <br /> Manifest Reference Number. <br /> 18b.Afternate,Facility(or Generator) U.S.EPA ID Number <br /> LL. Faellidys Phone: <br /> 0 <br /> uj I Be.Signature of Alternate Facility(or Generator) Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU I -t' 4: i 2. 3. 4, <br /> 20.Designated Facility Owner arpperator.Certification of receipt cf.hazardous matirialls,covered by the manifest except as noted in Itej I Ba <br /> PrintedlTyped Name !, :! 71 1, Siglature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obs6lete.z DESIGNATED FACILITY'S COPY <br />