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Please Print or type 1Fonn desi ned rot use on allte(12-pitch)typewriter <br /> PI9p: UNIFO Form APM sed{)M6 no t"�+;""tV <br /> WASTE NAZARDOUS 'Gw+aretw In NumEer SKS} ,MANIFEST :Paee I o1 T EmerpencY kaspunse Pnune a wr.a 0 S <br /> I5 Generalor•s Nam —1 MaliN Adnress J <br /> ceneralol.sno Adnra..of mn«rem mai mating address <br /> Generator's Phono. <br /> 6.Transporter,Company Name <br /> V.S.EPA ID NumOee <br /> T'ansWrior 2 Company Name <br /> U S EPA ID Number -. <br /> A Designated Facility Name and Sile Address <br /> U.S.EPA ID Number <br /> t� <br /> Fa0h 's Phone: <br /> 9a. 9b.U.S DOT Descnphon(including Proper Shipping Nama,H-aro Class,ID Numher, <br /> HM and Packing Group(if any)) 10 Containers 11.Tocol 12 UnGodes <br /> n t Neste <br /> oi� Ni Type Quantity <br /> O <br /> 1-- <br /> C Q <br /> O rr <br /> t– W <br /> a z <br /> � w <br /> u c7 <br /> u <br /> C <br /> I <br /> ) <br /> I <br /> I �' 14.Special Handling Instructions antl ore,'—rrn.hon <br /> 15, GENERATOR'S/OFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged. _ <br /> marked and labeled/placarded,and are in all respects in proper condition for are <br /> acwrdi"to applicable international and national governmental regulations.If export shipment and I am the Pnor ry <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I cerfily that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)lift am a small quantity generator)is true. <br /> Generator's/OBeror's Pdnfed/Typed Name <br /> Signature Month Day '(ear <br /> —t 16.IntemafioneShipments <br /> ~ <br /> LJ import to U.S. <br /> Transporter signature(for exports only) LJ Export from U.S� Port of entry/exit: <br /> . W 17.TransporterAcknowledgmento/Receipt of Materials Dale leaving U.S.: <br /> W Transporter 1 Printed/Typed Name <br /> O <br /> W Signature Month Day Year <br /> QTransporter 2PrintedlrypedName I I I <br /> I y+crule Month Day Year <br /> I 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ED Quantity <br /> EJType ❑Residue <br /> ❑Partial Rejection ❑Full Rejection <br /> It 18b.Alternate Faality(or Gene a�or) <br /> _� Manifest Reference Number: _ <br /> riU U.S.EPA ID Number <br /> Facility's Phone: <br /> easonable <br /> W 18c.Signature ofAlternate Facility(or Generator) <br /> Q <br /> Z Month <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling Day Year :y •' <br /> 9 Ht 1 2. Y ng systems) J �w <br /> 3. <br /> 4. <br /> 20,Designated Facility Owner or Operator.Certificat on Of receipt of hazardo s a e <br /> Printed?yam Name ate r:uverea by the manifest except as noted in Item 18a <br /> Signature <br /> EPA Form 8700.22(Rev,3.05) Previous editions are obsolete. on Day ear <br /> GENERATOR'c IMITil w k „___ <br />