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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No,2050.0039 <br /> UNIFORM HAZARDOUS 1,Generator ID Number2.Page 1 of 3,Emergency Response Phone 4,Manifest Tracking Na!umbe^rr <br /> WASTE MANIFEST 14 8 -15 JJ K <br /> 5.Generator's Name and Mailing Address _ Generator's Slfe Address(if different than mailing address) <br /> J. <br /> Generators Phone: <br /> 6.Transporter�1�CorripanyName U.S:fPA,ID Number' <br /> , <br /> 7.Transporter 2,Company Name U.S,EPA ID Number <br /> 8.De I rt jed, acllit�Na pd Site Add ss. U.S.EPA ID Number <br /> st9A l � s t pie- Tki ,if.Jj-_ <br /> Faclllty's Phone: <br /> 9a. tib.U.S,DOT Description(Inciutling Prop OFF <br /> Name;Hazard Ciess ID N' b' 10.Containers ,11 Total: 12.Unit 13.Waste Codes <br /> HM and Packing Group(If any)) <br /> No. Type Quantity Wt.Nol, <br /> ;{, 1. 3 ff1� tit:°..3`,'1 to rwfatlti ytJf3 Sa jy,,1 fyz43L 1C1a1<t ;i,r is <br /> JJTT <br /> 3, <br /> 4. <br /> 14,Special Handling instructions and Additional Information <br /> (;,'.l ? +�x•1�.,1.f lt!`�t'zl;'1 ��` �a���`��� !''( t' z`ft..t'?`r <br /> VI w.4 <br /> 15: GENERATOWS/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 transport according to applicable International and national govemmental regulations,if export shipment and I am the Primary <br /> Exporter,I certify that the oontents of this cohsignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement Identified in 40 CFR 262.27(a)(if I am alarge quantity generator)or(b (if I am a smal uantity generator)is true. <br /> Generators/Offerors Printed ed Name Signatur Month Day Year <br /> A'Pill A� V � � ,� } p@p@ r �•y <br /> _r 16.International Shipmew v k ` <br /> Z Ig8v to U.S. ❑Export from U.S. ort of miry exit: <br /> Transporter signature(for exports only): bate lea'g,U.S.: <br /> W 17.TransporterAcknowledgment of Receipt of Materials <br /> Trans rter t Printe• ed Name <br /> PR.v ,t:,_,. Agmg Signature'�. e � k � Month Day Year <br /> O <br /> Z Transporter 2 Printedrryped Name Si nafure" f <br /> 9 t Mbnth Day Year <br /> F- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue <br /> ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> ua FacilitysPhone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Z <br /> 19,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU <br /> 2. <br /> 20.Designated Facility Owner or Operator:Certification of receipt.of hazardous materials covered by the manifest except as noted In Item 18a <br /> Printed/rypad Name / Signature ,? /;' Month Day Year <br /> 1 ��� 1J' !^, '' �,. �" ,rr~',.r :' .tie �.�s^.k,t_4 f.;" /.`�✓i'. ..^�.�d.�..Le..J� J' �'� C�=�li'. f, ' <br /> EPA Form 8700-22(ReG,3 05) Previous edihofis;are obsolet. ✓ TRANSPORTER'S COPY <br />