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C: i— ri-I f- -a m alith M-riitr.hl tvnpwfTtpr I <br />Form Approved. OMB No 2050-0039 <br />1.1-1 <br />. I,Jr.,1 <br />UNIFORM HAZARDOUS <br />I Generator ID <br />�u <br />11 - <br />2. Page I of <br />-------- <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />F-- <br />--, :_. JJK <br />WASTE MANIFEST <br />J <br />� . -%:-- . <br />Generatoes.Nampand .Mailing.Address,,- <br />Generators Site Address (if different than mailing address) <br />Generators Phone: <br />6 Transporter 1 Company Name <br />U.S. EPA ID Number <br />7. Transporter 2 Company Name <br />U.S. EPA ID Number <br />8 Designated Facility Name and She Address <br />U.S EPA ID Number <br />.2- <br />1,174 <br />WOO..,. <br />Facility's Phone: <br />q <br />,a <br />91b. U,S DOT Description (including Pro <br />r Shipping Name, Hazard Class, ID Number, <br />10. Contaii ers <br />1. Total <br />12, Unit 13 Waste Codes <br />No 1 <br />Type <br />HIM <br />and Packing Group <br />Quantity <br />Wtfvol. <br />0 <br />Z <br />7. <br />REC <br />I L <br />3 <br />I <br />EB 18 2014 <br />4, <br />I <br />ENV <br />RO MENTAL <br />HEA <br />H <br />T I I <br />D PARTMENT <br />14 Special Handling Instructions and Additional In <br />-943 If <br />birmation <br />4 O'B". .121" lk� --!VF. <br />EPA C.-ODE0 : <br />R.; -WINE <br />15. GENERATOR'S/OFFEROR'S CERTIFICATI <br />)N: 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 labeledtplacarded, and are in all <br />espects 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 co <br />' gnment conform to the terms of the attached EPAAcknowledgment of Consent. <br />I certify that the waste minimization stWateme n�i <br />identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (KI am a sTallquaRlity,<Jenecator) is true. <br />Generatoes/Offerors Printed/Typed Name <br />Signature Month Day Year <br />, I t; <br />-1 <br />im- <br />16. International Shipments❑Port <br />Ellmportt <br />U.S. El Expert from U.S. of entry/exiL- <br />Transporter signature (for e ports'only) <br />1 <br />Date leav-Mg U.S.: <br />LQ� <br />U <br />17 Transporter Acknowledgment of Receipt of Mate'als <br />- <br />Transporter I Prin <br />--!OC�ypecl Name <br />Signature . I ; I i Month Day Year <br />1 1. - <br />it <br />0 <br />CL <br />Cf) <br />Z <br />Transporter 2 Phntedrryped Name <br />Signature Month Day Year <br />18. Discrepancy <br />laa. Discrepancy Indication Space L Qua <br />tity Type ElResid ue ❑ partial "ad. ❑ Full Rejection <br />Manifest Reference Number <br />18b. Alternate Facility (or Generator) <br />U.S. EPA ID Number <br />u - <br />Facility's Phone: <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />Z <br />19. Hazardous Waste Report Management Method <br />;odes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />2. 4. <br />- <br />A- <br />T <br />20. DesignatecIFacility Owner or Operator. Cerbliba <br />20. <br />ion of recopt of hazardous materials covered by the manifest except as noted in Item 18a <br />Nauia� <br />7: Signature MOM Day Year <br />EPA Form 8700-22 (Rev.3-05) <br />Previous editions re ODS011elle. <br />:--=S7r--NATF-L) eAll I Y I U =NtZi-IFki VM ZJ [All = 1,1117 r1l=WUIMr-i:J, <br />