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Please print or type,(Fo ' esigned for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> 1 Generator ID Number 2.P e 1 of 3.Emer en R <br /> UNIFORM H OUS a9 9 espouse Phone 4.Manifest Tracking Number <br /> WASTE IFEST , f f►>aP . I ) iC' <br /> JJK <br /> 5.Generator's Name and Mailing Address Generator's Site Address d different mailing add <br /> Pc%VA <br /> t:.fes,+,��d`y !; �' 1 ( w'.i .k; � + S��*.�•. i �. + S , .. �.'s z �, `"� .. <br /> Generators Phone: k �j ✓~C.► S G t0 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> !' T C? <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Designated Facility Napue and Site Address U.S.EPA ID Number <br /> L�: w Firs: St . Azu � IL f" 4►'1 , :. <br /> Facility'sPhone: <br /> ?. <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 /> ( f No. Type Quantity Wt.Nol. <br /> W } <br /> Lk rq <br /> Z 2. <br /> W <br /> CD <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additionaprifonnation <br /> C <br /> 15. GENERATOR'SIOFFERORIS 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 laWed/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 EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generators/Offerors Printed/Typed Name Signature Month Day Year <br /> 16.International Shipments <br /> 1— ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> K Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name Signature Month Day Year <br /> Q <br /> a <br /> Q Transporter 2 PdntedfTyped Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ quantity ❑Type ❑Residuefectio <br /> ❑Partial Rejection El Full Rejection <br /> Manifest Reference Number: <br /> 18b.Altemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Facility's Phone: <br /> W 18c.Signature ofAltemate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> N19,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. 2. 3. 4. <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. GENERATOR'S INITIAL COPY <br />