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5 ' <br /> Please print or type.{Form designed for use on wife(12-pitdt)c.) Form moved.OMB No.2050-0039 <br /> UNIFORM QOUS 1.Generator ID Number 2.Page 1 of 3. Phone 4 Tracking Number N <br /> WASTE MANIFEST JJ <br /> 5.Generators Name and Mitifir ig Address Generators Site Address(if different tharn mating address) <br /> Generators Phone: <br /> 6.Transporter 1Company Nara U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Sit-Address U.S.EPA ID Number <br /> Fax7ity's Phone: <br /> 9a. 9b•U.S.DOT Description(including Proper Shipping Nam,Hazard Class,ID Number, 10.Containers 11.Total 12,Unit 13.Waste Codes <br /> HM and Packing Group(d any)) No. Type quantity wt./Vol. <br /> Z 2. <br /> 'W <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional lnbmdm <br /> 15. GENERATOWSIOFFERWS CERTIFICATION:I hereby declare that the of this consignowit are My and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labelediplacarded,and are in all respects in proper oondilion for transport according to applicable international and national governmental regulations it export shipment and I am the Primary <br /> Exporter.l certify M the contents of this consignment omfomn to the terms of the attached EPAAdwMedgment of Consent. <br /> I oerlfy that the waste mmintization statement identified in 40 CFR 26=(a)(d 1 as a large quagity or(b)(NI am a small quantity genemM is We. <br /> Generatcrs/Offerors Printed/typed Name Signapxe Month Day Year <br /> J 16In <br /> i— El import to U.S. ❑Exp <br /> . ort from U.S. Port ofen�/exit <br /> Transporter exports <br /> (for only): Date <br /> IX 17.T of Receipt of Materials <br /> Transporter 1 Printed(fyped Name Swalure, Month Day Year <br /> O <br /> aTransporter 2 Prbntedffyped Nam Signature Month Day Year <br /> Fes- <br /> 18.Discrepancy <br /> 18a_Discrepancy Indication Space ❑ Quaff ❑Type ❑Reskkre ❑Partial Rejection ❑Fu0 Rejection <br /> Manifest Reference Number <br /> 18b.Atiemat-Facility(or Generator) U.S.FPA ID Number <br /> cs <br /> U. FacaWs Phone: <br /> w 18c.Sigrnabae ofAlternate FacrTty(or Generator) Month Day Yea <br /> 4 <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment dislowal and recycling systems) <br /> uj® 1, 2. ::1- <br /> 4. <br /> 20.Designate!Facility Owner or covered by One manifest except as noted in Item Ise <br /> yped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous edftns are obsolete. 3 <br />