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Please printor type-.(Form designed for use on elite(12-pitch);typewriter) Form Approved OMR No.2050.0039 <br /> UNIFORM HAZARDOUS I.Generetoel0 Number Z Page 1 of 3.EmergencyRe"sponse Phone A, lanifest Tracking Number <br /> WASTE MANIFEST t "' _ ` JJ IK <br /> 5.Generator sNa"iite atnd Mailir g Address. '' Generator's Site Address(If different than mailing address) <br /> ne ..r. _.. <br /> Generator's Phone: <br /> 6.Trao5porta[9 Company,Name� U.S.EPA ID Number' <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designatep Facility Name and Site Address U.S,EPA'ID Number <br /> Facility's Phone: <br /> ga, bb.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10,Containers 11.Total 12,Unit 13;Waste Codes <br /> HM and t,qc�ng Group(if qny)) No. Type Quantity Wt:Nol, <br /> Qd .... a 11 i <br /> Z 2. <br /> LU <br /> 4, <br /> I <br /> 14.Special Handlirig Instructions and Additional Information t,r <br /> 1 <br /> 15, GENERATOR'SIOFFEROR'S CERTIFICATION: Ihereby declare that the contents of this:consignment are fully and accuratelyd0sodbed above by the proper shipping.name,and are classified,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable intemationaland national governmental regulations._if export shipment and I am the Ptlmary <br /> Exporter,I cer8fy that the contents of this consignment conform to the tens of the attached EPAAcknowledgmeniof Consent. <br /> I certify that the waste minimization statement identified in 40'CFR 262.27(a)('d l am a large quantity generator)or:(b),(ff{am a small qua.ntity generator}'is true, <br /> Generatorsl0fferorsPnntedf ypedName SignatuC � .r Moth Day Yaar <br /> ; <br /> —j 16.InternationalShipnents <br /> i— ❑Import to vs. ❑Export from U.S, `Pod of entrylexiC <br /> Transporter.signature,(for exports only):' Date leavingU,S,;. <br /> 17.Transporter Acknowledgment of ReceiptofMaterials s <br /> Transporter)Prirt--, Typed AT .i Signature ) 411s Month Pay Year <br /> a. <br /> Transporter 2 PrintedtTyped Name Signature Month Day Year <br /> 18,Discrepancy <br /> I8a.Discrepancy Indication Space <br /> ❑ Quantity` 1:1 Type E-1 Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b,Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U; <br /> u facility's Phone: <br /> W 18c.Signature of Alternate,Facility(or Generator) Month Day Year <br /> .Q <br /> Z <br /> ' 18.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous wast6.treatment,disposal,and recycling systems) <br /> LU P 1. f' 2; 3, 4 <br /> f ; <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as ncte3 in.11em 18a <br /> Printedl'f a Name X. <br /> YP p rSignature Month Day ear <br /> EPA Form 8700-22(Rev;3.05) Previous editions are obsolete, TRANSPORTER'S COPY <br /> i <br />