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PleasePrjnt or type(Fern designed(or use an elite(12-pitch)typewriter) <br />.. UNIFORM HAZARDOUS t Generator ID Nwnser <br /> WASTE MANIFEST z Pape t a 3 Fora,pypro.red.gpt5 No Zr15p-00.19 <br /> 5.GenereloYs Name and Mailmy Address EmergeMy R�°n'a Phone e.wiimftN T n yrneer <br /> JJK <br /> 1r Genealorn sire Adera®la emerw,l u,an <br /> 'y maserp MdHs1 <br /> Gene ator's Ph.". or , <br /> 6 Tansporter i company Name NIFEST <br /> U.S.EPA I I/omGar .� <br /> 7. ansponer 2 Company Name <br /> (AG <br /> US EPA ID Numl- <br /> B Designated F-1 1A Name and Site Atltli-sr, C w <br /> US EPA ID N.mbe, t/ <br /> Facility's Phone- <br /> pea <br /> ga_ 9D U S.DOT De=rr �..,!„ndudin Pro r Shipping !K <br /> HM and Packing Grout,��.,v,l g PDing Name.Hazard Class.ID Number, 10.Containers 11 Toy, 12 Un,l <br /> 13 Waste COMB <br /> � No T- 1!!,. <br /> O <br /> t— <br /> Q 1 <br /> w <br /> z <br /> w <br /> r, <br /> Special Handling Inslnclions and Additional Inromnation <br /> �g <br /> 15. <br /> GENERATOR'S/OFFERORS CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name.and are classifed,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and 1 am the Pnmary <br /> Exporter.I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generator's/OBerol's Printed/Typed Name Signature Month Day Year <br /> Ay <br /> _j 16.International Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of entrylexil: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> LU 17.TTansporterAcknoMedgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name Signature <br /> OMonth Day Year <br /> N <br /> / Q Fransporter2 Printed/Typed Name Signature <br /> Month Day 'r�e,r <br /> 16.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> EJ _ <br /> Quantity ❑Type ❑Residue Partial Rejection Full F.;ecnen <br /> Manifest Reference Number: <br /> F}- 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> if Facility's Phone: <br /> 1r1 w 18c.Signature ofAllemate Facility(or Generator) <br /> G Q Month Day Yea <br /> e r' <br /> z <br /> 10 f C7 19 Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> a LU <br /> f 1 2. 3. 4 <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> ponied,7N2d i'iamc <br /> Signature Month Day Year <br /> sera EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> GENERATORS INITIAL COPY <br /> Ug <br /> costs ands <br />