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Please print or type. (Form designed for use on elite (12•pit ) ty ewriter.) <br /> 1 . Generator ID umber Form Approved, OMB No, 2050-0039 <br /> UNIFORM HAZARDOUS <br /> N 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number <br /> WASTE MANIFEST <br /> " ., <br /> 5. Generators JJK <br /> Name and Mailing Address Generator's Site Address (if different than mailing address)if <br /> " <br /> . e <br /> Generator's Phone: V' <br /> 6. Transporter 1 Company Name <br /> U.S. EPA ID Number <br /> ,1 a b � <br /> 7. Transporter 2 Company Name <br /> U.S. EPA ID Number <br /> r. <br /> 8. Designated Facility Name and Site Address <br /> U.S. EPA ID Number <br /> s ii <br /> Facility's Phone: i ff "`•I ;. <br /> 9a, 9b. U.S. DOT Description (including Proper Shipping Na e, H zard Class, ID Number, 10. Containers <br /> HM and Packing Group (if any)) 11 . Total 12. Unit 13. Waste Codes <br /> No. Type Quantity Wt.Noi. <br /> 1 1 ,, <br /> O 6 <br /> Old ' <br /> �.....� hr ..,...c • a <br /> Z tg <br /> t UJI <br /> THIS WASTE STREAM iAS BEEN QUALIFIED <br /> t FOR RECYCLING/TRE 'TM NT AT THE <br /> eMENNO/KCRDOON )BA WORLD OIL I <br /> 34 <br /> RECYCLING FACIE <br /> THIS FACILITY HAS ll E N :CESSARY PERMITS TO <br /> RECEIVE YOUR WAST STREAM AS QUALIFED• <br /> F- PAIJIIKA13FRIS AT 80013352 <br /> 4. <br /> 14. Special Handling Instructions and Additional Information <br /> 15 3 • . . - ff . .. . <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby di clare hat the contents of this consignment are fully and accurately described above by the pioper shipping name, and are classified, packaged, <br /> marked and labeled/placarded, and are in all respects in prol er coi dition 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 confo : to 1 ie terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 4C CFR 62.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br /> GeneratorslOfferoPs Printe /Typed NameIfSignature Month Day Year <br /> If <br /> al <, <br /> 14 <br /> —r 16. International ShipmentsvIf <br /> ❑ Import to U.S, ❑ Export from U.S. Port ofentry/exit: _ <br /> Transporter signature (for exports only): Date leaving U.S;. <br /> W17, TransporterAcknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name Signature <br /> ® Month Day Year <br /> ; <br /> o. i <br /> Z Transporter Pdntedfryped Name r <br /> Signature Month Day Year <br /> N <br /> 18. Discrepancy <br /> 18a. Discrepancy Indication Space <br /> ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number: <br /> (� 18b. Alternate Facility (or Generator) U.S. EPA ID Number <br /> L) <br /> w Facility's Phone: <br /> LU18c. Signature of Alternate Facility (or Generator) Month Day Year <br /> y19. Hazardous Waste Report Management Method Codes (i.e., cod " s for azardous waste treatment, disposal, and recycling systems) <br /> ® 1r ~` 2. 3 4, <br /> 20. Designated Facility Owner or Operator: Certification of receipt ol hazai Jous materials covered by the manifest except as ndedin item 18a <br /> Printed/ Name 9 to t <br /> Si " re <br /> Mont <br /> h Day <br /> Year <br /> t "# <br /> EPA Form 13700-22 (Rev. 3.05) Previous editions are obsol01 <br /> ete, ' <br /> fit vit 11Pff ; if) r GIL I TV r0 �, UNF. HA�` F1 <br />