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Please print or type.(Form designed for use on elite(dpitui)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZACDOUS I.Generator ID Number 1 1 2.Page TRTMEmergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST 7 y to( JJK <br /> 1 0/&V,)lf I L�" <br /> 5.Geneiators Name and Mailing Address Generator's Site Address(if dFffnt than mailing address) <br /> Generator's Phone' G'.6.Transporter 1 Company Name r U.S.EPA ID Number <br /> 7.Transporter 2-Company Name <br /> U.S.EPA ID Number I 1C <br /> 8 Des <br /> _0 <br /> Name ani Site Address <br /> ated Facility U.S.EPA ID Number <br /> Facility's Phone: -A' <br /> 99 <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quantity WLNOL <br /> O <br /> YdLU <br /> Lu <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> gar W;"CA" <br /> Ahtl <br /> � l <br /> z <br /> c C <br /> F-V <br /> r, 1. r i f ir1 :14,4 <br /> .45. GENIERATOR'SIOFFEROR'S CERTIFICATION: I hereby'declare that the contents of this consignment are fully and accurately desc6bed above by ft pr6pershipping name,and are classified,packaged, <br /> marked and laWed/placarded,and are in all respects in proper condition for transport according to applicable intemabonal 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 EPA Acknowledgment of Consent <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(ff I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generators/Offeror's Printed/Typed Name Signature Month -Day Year <br /> 1,'vrr .,Lt .7 <br /> 1E Interriational Shipments <br /> ElImport to U.S. El Export from U.S. Port of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> wJLTransporter Acknowledgment of Receipt of Materials <br /> OTransporter 1 Printed/Typed Name Signature Month Day Yew <br /> 0 <br /> CL <br /> ;Z TYansporter 2 Printed/Typed Name Signature <br /> Mofffi Day Year: <br /> I18.Discrepancy <br /> 18a.Discrepancy Indication Space El Quantity 0 Type El Residue 0 Partial Rejection ❑Full Reject I!on <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> C-3 <br /> .1 <br /> Facility's Phone: <br /> Uj 18c.Signature of Aftemate Facility(or Generator) Month <br /> Month Day Year <br /> = — 1 L <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 9= 1. 11 K — 1 2. T 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in ttern 18a <br /> Printed/Typed Name Signature. Month Day Year <br /> P <br /> EPA Form 8700-22(Rev.3-05) Previous:editions are obsolete. REULIVEU W U4 LUM TRANSPORTER'S COPY <br />