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Please print or type.(Form designed for use on elite(12-pitch)typewriter) <br /> UNIFORM HAZARDOUS 1 Generator ID Number2.Page I of 3,Emergency Response Form Approved.OMB No.2050-0039 <br /> a Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST 0,1 <br /> JJa®5,Generators Name ndM i dress <br /> A, Mrs NTA Address(if different than mailing address) <br /> zv <br /> Geh-re 'sPhone t, <br /> 6.Transporter I CompanyName <br /> U.S.E <br /> 7.Transporter 2 Company Name <br /> U.S.EPA ID Number <br /> ADNumber <br /> I ,- <br /> 'A ID Number <br /> n <br /> 00ress. U.S.EPA ID Number <br /> Facility's Phone: <br /> 9a. 9b.U.S.DOT Deslirlption(including Proper Shipping Name,Hazard Class,ID Number; <br /> HM and Packing Group(if any)) 10.Cohtalriers�. '11.Total <br /> 12.Unit 13.Waste Codes <br /> 1. No. Type Quantity Wt./Vol. <br /> ; oriIJ! <br /> 0 <br /> 2,UJ <br /> _l <br /> 0 <br /> 3. <br /> 2 <br /> 4 <br /> 1 Special <br /> 4. ,�'al Handling 1, <br /> op�cial�riandhnq instructions and Additional Information <br /> '7 <br /> hereby—d,-rJ.,.that fh. y described above by the proper shipping name,and are classified,15. GENERATOR'S/OFFEROR'S CERTIFICATION: I ereby declare that the contents of this consignment are fully and accurately <br /> I <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 I am t d,packaged, <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. he Primary <br /> I certify that the waste minimization statement Identified in 40 CFR 262.17(a)(if I am a large quantity,generator)(�r(b)(if I am a s mall quantity generator)is true. <br /> .............. <br /> Geneptor'NOfferl i I ril 111 �Jarnp <br /> 911a ure <br /> Month Day Year <br /> . ..... <br /> H16.International Shipments 'k <br /> R import to U.S. <br /> Transporter signatureE6p6d from ds­ <br /> Pon of entry/eAt. <br /> 17.TranspoderAcknU.S.: <br /> owledgment of Receipt of Materials <br /> Transporter 1 PrIntedfryped Name <br /> 0 SrgnahTra <br /> IL Month Day Year <br /> co <br /> Z Transporter 2 Printed/Typed Name _I, <br /> "Signature;„„,,, <br /> Month <br /> Day Year <br /> 18,Discrepancy <br /> 18a,Discrepancy Indication Space <br /> E1Quantity El Type ❑Residue F-1 Partial Rejectionr❑Full Rejection <br /> 18b.Alternate Facility(or Generator) Manifest <br /> Reference Number: <br /> U.S,EPA ID Number <br /> U<. Facility's Phone: <br /> 18c.Signature ofAlte ateFacility(or <br /> LU <br /> Z Month Day Year <br /> V5 19.Hazardous Waste Report Management Method Codes(Le,,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU 1. <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/Typ.0 Name <br /> Signature <br /> Month Day Year <br /> .[-A Form 8700-22(Rev.3-05) Previous edi lon;"are obsolete. <br /> TRANSPORTER'S COPY <br />