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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OM8 No 205MO39 <br /> UNIFORM HAZARDOUS I":"=TMdLQF IIJ NUMDU <br /> 2.Page I of 3 Ernergency Response Phone —]4.M Tracking M <br /> T • I of 3-F--;�F Number <br /> WASTE MANIFEST <br /> 5.Generators Name and WlingArldress— <br /> -j-- L'b JJK <br /> 'A.4 i,.1 1 •Generators Site Addrass•qt different than mauling address) <br /> 6.Transporter I Company Name <br /> U.S.EPA ID Number <br /> TTransporter 2 Company <br /> U.S. <br /> B.Designated FaaTty Name and SileAddress <br /> EPA ID Number <br /> Facifity's Phone: <br /> 2, 9b,U.S.DOT'Description(including Pr0PerShi;ping Name,Hazard Class,ID Number, 10.Containers <br /> HM and Packing Group(if any)) 11.Total 12-Una <br /> 1. :%_ - - �7 :- -. - - - No. uanuty WWOL 13.Waste Codes <br /> U.S.U <br /> 11- <br /> S. <br /> To <br /> EPA <br /> ty- <br /> A <br /> I <br /> D <br /> ID <br /> Number <br /> *Quan <br /> Z: 2. <br /> LU <br /> k <br /> 3. <br /> Y.)e <br /> 14.Special Handing IrsUuctiors andlinal <br /> !on <br /> 15. GEN ERATOR'SIOFFEROR'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 labele#lacarded,and are in all respects in proper condition for transport aci;crifing b applicable international and national governmental regulations,If export shipment and I am the Primary <br /> Exporter,I certify[hat the contents of this consignment conform to the terms of the attachved EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)Cif I am a large quantity generator)or(b)(ifl am a small quantity generator)is true. <br /> Generators/Offerors Prin(ecgyped Name <br /> Signature <br /> hbNh Day Year <br /> ri 16.International Shipments <br /> ❑I mpod to U.S. El Export from U.S. !Port <br /> o entrylexit: <br /> Transporter signature(for exports only): Date leaving U.S-" <br /> L C� 17.Transportei-Acknowledgment ofReceipt ofMateUs <br /> Transporter I PrintediTyped Name i <br /> 0t Month Day Year <br /> r1-1 '.. I <br /> a_ tf; tj' <br /> ;Z Transporter 2 Printed/Typed Name <br /> Month Year <br /> F- <br /> '18.Discrepancy <br /> 18a:Discrepancy Indication Space Type ❑Residue ❑Partial Rejection ❑Full Reif. <br /> Manifest Reference Number <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> at <br /> E5 <br /> u- Facilly's Phone: <br /> C3 1 <br /> LLJ8c.Signature&PAerriale Facilay(or Generator) �latltll <br /> Day Year <br /> 19.Hazardous Waste Report Management Mellmd Codes(.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LLI <br /> 2 r3. k I t 4 <br /> "D i <br /> 20.Designated Facility Owner or Operator.Certification afreceipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed yped Narne- <br /> Si nature htolmt Dy�Y- <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete, <br /> DESIGNATED FACILITY TO GENERAMR <br />