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.. ................ <br /> Please pril,t cr type.(Form designed for use on elite('2-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1-Generator ID Number2.PEmergencyof 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST <br /> it <br /> J 4,3 z)8 4.ij J J K <br /> 5.Gerislr?toft-Nal pr4 Mail address..... :. <br /> Generators Site Address(If different than mailing address) <br /> Generator's Phone: <br /> 6,Transporter I Company Name J.S.EPA ID Number <br /> 7.Transporter 2 Company Narre U.S.EPA ID Number <br /> gk, J.S.EPA ID Number <br /> Facility's Phone: <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Nal Hazard Cass,ID Number, 10,Containers 11 Total 12,Unit. 13.Waste Codes <br /> HIM and Packing Groupfif any)},,, No. Type Quantity Wt.Nol.." <br /> z 2. <br /> 3. <br /> FEB'1 7 2016 <br /> 4. <br /> E VIRONMqNTP L <br /> H 1114 tWPAP k#CKI*r <br /> 14.Special Handling Instructions and Add;ticnal Inlormaltion <br /> 74� <br /> AL <br /> T I <br /> 15. GENERATOR'SIOFFEROR'SCERTIFIPATION: I hereby declare that the contents of this consignment are hilly and accurately cescribed above by the proper shipping name,and are t1mified,packaged, <br /> marked and lariele6placarded,and are h all respects in proper condition'or transport according tc applicable international and national governmental regulations:f export shipment and I am the Primary <br /> Exporter,I carlify,that the contgnts of this gonsignmeit coilorm to the terms of to attached EPA AcknoMedgmenti of Consent. <br /> tion§ra�rge%jeiill <br /> st4ilp!rl , I am a large quant ity generator)or(b)(141 am a small q4 cirl):s,true, <br /> at bwp <br /> GaneratqSignature Month Day ear <br /> 00=13 PrinlIpOtTypeo-Name. <br /> .J 16,international Shipments <br /> r— 11 Import to U.S. El Export from U.S. Fort of eri <br /> 3 Transporter signature(`or exports only): Date eaving U.S. <br /> lX 17.TransperterAcknowledgment of Receipt of Mattel <br /> UJI <br /> Trarm,p%ler PrintedrTyped Name, Signature Month Day Year <br /> Oat ...... <br /> ? <br /> QTransporter 2 PrintedliTyped Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space F Cuantlity El Type Residue Partial Reject-or Full Rejel <br /> Manifest Re*wca Ninl <br /> 18b.Aftemate Facility(or Generator) U'S.'EPA ID Number <br /> to <br /> viol Facility's Phone: <br /> Lu <br /> Month bay Year <br /> Z <br /> 18c.Signature of Alternate Facility(or Generatl <br /> 0 <br /> rn 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU <br /> 1. 2. 3. 4. <br /> F20—Designated Facility Owner or Opal Cartificat cn of receipt of hazarcous materials covered by the man fest except as noted in item 18a <br /> Prntedrfyped Name I Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR STATE(IF REQUIRED) <br />