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(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> AZARDOUS 1.Generatc-ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> MANIFEST JJ K <br /> ror's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> denerator's Phone: <br /> 6.Transporter I Cornpq Namp U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> V,. <br /> Facility's Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> uJ <br /> LJ <br /> C7 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> !r{,l �iy�lr..(!hSP! <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment 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 applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantlbIgenaca or)or(b)(if I am a small quantity generator)is true. <br /> Generatoes/Offeroes Printedgyped Name,'t Signature , Month Day Year <br /> It J <br /> –J 16.Intemational Shipmeo <br /> r— ❑Import to U.S. ❑Export from U.S. Port of entrylexit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> IX 17.Transporter Acknowledgment of Receipt of Materials <br /> �; Transporter 1 Printed/Typed Name Signature Month Day Year <br /> CL <br /> Z Transporter 2 Printed/Typed Name Signature+ Month Day Year <br /> a <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type Residue Partial Rejection El Rejection <br /> Manifest Reference Number. <br /> 181b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> Lj- Facility's Phone: <br /> w 18c.Signature of Alternate Fadlity(or Generators Month Day Year <br /> Q <br /> Z <br /> 55 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> w 1. l i f 2. 3. 4. <br /> r� ,� ter' <br /> %'I t <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item'18a <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />