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Please print or type,(Form designed for use on elite(12-pitch)typewriter,) Form Approved.OMB No.2050-Q039 <br /> Generator ID Number <br /> UNIFORM HAZARDOUS 2 age P 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> 1 <br /> WASTE MANIFEST JJK ' <br /> 5.Gapefatoes.Neme and Mailing Address Generator's Site Address(if different than mailing address) <br /> Generator's Phone: <br /> 6,Transporter 1 Company Name U S,EPA ID Number <br /> 7,Tr4nsporter 2 Company Name U.S.EPA ID Number <br /> 8.Desig%1 4 Facility Ram@,ql SitQ.4dress U.S.EPA ID Number. <br /> Facility's Phone: <br /> 9a. 9b,U.S,DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) <br /> No. Type Quantity Wt.NoL <br /> = 1. '! ... Tt',r, t.'ifi'�, ....t,t�;.rr.,. t ... tb,. ;>..t,tlt IT���•Q tY 1 i;l .. .f;`Sly .... .... . <br /> W 2. <br /> Uj <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> k <br /> r'; r 0dl-� <br /> 15. GENERATOR'SIOFFEROR'S.CERTIFI,CAVON,,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 respe$ts,in proper condition for transport according to.applicabie international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents 0f this wns)gnmett conform tofthe terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization stales. "dd'e ti ed 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 /> Generators/Offeroes Prioted/ryped Name x Signature, - Mogth Day Year <br /> 16.International Shipments <br /> F ❑Import to U.S. ❑Export from U.S, Port of entry/exit: <br /> Transporter,signature(for exports,only): Date leaving U.S <br /> W 17.TransponterAcknowledgment of Receipt of Materials <br /> O Transporter 1 RrIntedlT yped Nam f Signature " F , Mo th Day <br /> sss ' tYear <br /> CL } <br /> aTransporter 2 Printedlryped Name I } Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space 0 quantity ❑Type ❑Residue ❑Partial Rejection <br /> El Full Rejection <br /> Manifest Reference Number: <br /> 18b,Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> �V <br /> ua. Facility's Phone: <br /> uo 18c.Signature ofAitemate Facility(or Generator) _ Month Day Year <br /> Q <br /> Z . <br /> 19.Hazardous Waste Report Management Method Codes(I.e„codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 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 /> Printedfrypad Name Signature Month Day Year <br /> EPA Form 8700-22(Rev,3.05) Previous editions are obsolete, TRAN5POF3TER'S COPY <br />