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Please print or type.(Farm designed for use on elite{12-pitch)typewrites-) ' Form Approved.OMB Nb:2050 0039
<br /> UNIFORM HAZARDOUS
<br /> 1•GeneratorJQ,N1j ber 2 Page 1 of 3 Emergency Response Phone 4:Manrfest'[rac[Utrg Nut rrw m
<br /> WASTE MANIFEST ` '' JJK
<br /> 5 GeneratoYs Name a q Ma�I�ng l�ddjass ,f: }.- i a M GeneyatVs Site Address(if different than mailing address)
<br /> Generators Phone:
<br /> 6 Tran�SporterlpGo anyNae : U♦5 EPAID Iumgert { 3.:,
<br /> t
<br /> 7 Vagsporter 2 Company Name. i., f " U S EPA ID Number
<br /> ",,',i F b':•Iw r rs s�... i w } c z �r t. t
<br /> 8 Os7�nafied Facility Name aridzSate Address, U.S.EPA ID Numbet
<br /> FaglEfi}'s:Phone
<br /> ga 8li U,S:DOT Description{(nclutl€ng Proper SlitppNg Name'Hazard CEass ID Number 10 Contamers. .': 41,Total 12 Unit 13:Chaste Codes
<br /> HM ,.and'PkHng Group(if any)) No ;Type, Quantity. ... WtdVal:.,
<br /> a �--,��1 . a , - -
<br /> O V ` <t
<br /> LLI
<br /> 3. .
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<br /> 14 S eCialtandl(ng lnstrucbons anM.
<br /> dAdd trorjal Information , � _ >
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<br /> 15. GENERATOR Sf(JFFEROR S CERTIFICATION l:hereby declare that the contents of this consignment aha to11 Band accurately deserted sbdve'bythe proper shipping name,and are ciasshd,packaged,
<br /> marked'and Iabeledlplacarded and are!n all respects en proper con'ihanfor;transpbrt acG'ording10 applicable intemabona!and national governmental regulahons:ilf export sfijpment and lam the:Rrimary.
<br /> Expo ter,1 certify that the contents of.this consignment cordarm:tn the termS:pfthe attached EPAAcEcn:owledgmentiof Consent:
<br /> I certify that the waste minimization statement identified in 40.CFR 262 27(a}:(3f I am a largp quantity generator}oc.(b)(sf I a-.,a small,quantty generator)1s#rue:
<br /> Generat eslOfferors Pnntedrryped Name `f � Signature a I onth Day Year
<br /> 6A 16.International$hip,"menu
<br /> H Impart to U.S.' Exort.from U S Port bf entrylexiE
<br /> z Transporter signature(dor exports only}; 13ateyle�aving U.&,
<br /> '17.TransporterAcknowlkd6rn of Receipt,of Materials "
<br /> Transporter 1 PdntedfTyped Name j , Stgnafure, ,LU
<br /> " ,,,, ;,,� Math Day Year
<br /> Z Tra is orter2 Pn;#ed[T ed°Name Si nafure. t Month Da
<br /> Q R d yP ` y Year,
<br /> �. y., .:', �. f < i.'d+�d..ai :rt y,,,� 4 i .. 3 .✓V../ �' ,y.
<br /> 1:
<br /> 18..Discrepancy ,
<br /> 18a.Discrepancy Indication Space Q Quante : 0 ❑ R J' ❑Full Rejection
<br /> ty Type Residue:_ Parhai „eectfon
<br /> Manifest Reference Number.
<br /> 18b,Alternate Facility(or Generator) U:S EPA ID Number
<br /> C:V
<br /> :Facility's'Phone:
<br /> 18c.Signature of Altemate Facility{or Generator) Month Day Year
<br /> a
<br /> 19,Hazardous:Waste Report Management Method£odes(i a codes'forhazardous waste treatmBntdisposal,'srld recycling'systems}
<br /> 20:Designated Facility Owner or,Operator:Certification of receipt gftiaaardous mater€als covb'red by the manlfest ekcept as bowcr'ln Ilam 18a
<br /> PrfntedlTyped Name Signature Month Day Year._
<br /> EPA Form 8700.22(Rev.3.05).Previous editions are obsolete; TPA McPnRcps°,,r°r3P .
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