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PI.-ase print or type.(Form designed for use on elite(I2-pitch)typewriter.) Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1-Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> F7TT; V�e n 'i.) 7" r­ <br /> JJK <br /> WASTE MANIFEST <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> ? <br /> 5i4ji;i 1,0i V <br /> _ZA. <br /> Generators Phone: 0,111 m 7 <br /> 6.Transported`CompanyName U;S:EPA1D Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facltity Name and Site Address ,- r�ber <br /> U.S.EPA ID Nu <br /> Facility's Phone: <br /> 9a. 9b.U.S.DOT Descriptioni(Including Proper Shipping Name,Hazard Class,ID Number, 10.Containers,_, 1� 1.Total,: 12.Unit <br /> HIVI and Packing Group(if any)) I ­ '1 13.Waste Codes <br /> No. Type Quantity Wt.Nol. <br /> V <br /> J, 1ti11f.11 11 lij <br /> 3. <br /> 4. <br /> 74,—Special Handling Instructions and Additional Information <br /> 15.- GENERATOR'SIOFFEROR!$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 govemmentail regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I car*that the waste minimization statement Identified In 40 CFR 21512.27(a)(if I am a large quantity generator)or (if I am a smal/qd'anfity generator)is true. <br /> Generatoes/Ciflero' ad Name Signaturg Month Day Year <br /> ,)a Printer <br /> _j 16.International Shipmeht§,.,./ <br /> 0 lq&to U.S. El Export from U.S. dart of <br /> Z Transporter signature(for exports only): �ntry exit: <br /> Date lea e0u.S.: <br /> LU 17.TransporterAcknowledgment of Receipt of Materials <br /> Ix <br /> I'- I ra n s pAoerj s,Rrinteffyped Name Signature Month Day Year <br /> Z Transporter 2 Printedfryped Name Ilk, <br /> Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Spare ❑ Quantity, ❑Type D Residue 0 Partial Rejection El Full Rejection <br /> 18b.Alternate Facility(or Generator) Manifest Reference Number. <br /> U.S.EPA ID Number <br /> Facility's Phone: <br /> Cu3j 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(lie,,codes for hazardous waste treatment,disposal,and'recycling systems) ...... <br /> UJI 1 <br /> O <br /> 2. 3. <br /> I <br /> Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted In Item 18a tP6nt d"yped Name Signature <br /> Month Day Year <br /> X <br /> EPA Form 8700-22(Rev.3-05) Previous editiolis are obsolete' <br /> TRANSPORTER'S COPY <br />