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s <br /> Form Approved.OMB No.2050-0039 <br /> ease print or type,(Form designed for.use on elite(12-pitch)typewriter.) <br /> 1:Generator ID Number 2.Page 1 of 3 Emergency Response.Phone 4,Mani est Tragk)n�NpnJber�= i y <br /> UNIFORM HAZARDOUS . JJK <br /> WASTE MANIFEST <br /> 5.Generator s Name and Mailing Address Generators Site A,ddross(if different than mailing address) <br /> Generator's Phone: U,S;EPA.ID�Number�-r,•-: <br /> 6.Transporter 1,Company Name <br /> 7 Transporter 2 Company Name t <br /> U.$,EPA ID Number <br /> f r � . .:EPA ID-Number <br /> 8 Des€gnated Eacilify Name and Siie Address JJIr 4J r='l., 1 d {f}q/(F'£<i$d ti <br /> { Nit Y f' t`.fir r♦C=:� l� a�is yl a f` <br /> Facility s Phone: t k:t`� ` _ k t�,, •?+ 73 <br /> 9b.U.S.DOT Description(tnciu ling Proper`Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total 12,Unit U.Waste Codes <br /> 9a. No. Type Quantity Wt.Nol. <br /> HM and Packing Group(if any)) <br /> O <br /> Ir— <br /> Z 2. <br /> W <br /> O <br /> 3. <br /> 4. <br /> 14.Spocia Hagstructions and,Additionai Information <br /> o' e). r <br /> 15. GENERATOR'SI,OFI EROR',S.CERTiPICATIONt 1 hereby decade thaCthe contents of this,consignment are fully and accurately described above by the proper shipping name,,and are classified,packaged <br /> marked and lalieledlplaFarbed and,are In all respects in proper condition for transport according to applicable International and national governmental regulations:If export shipmenFand l am the Primary <br /> Exporter,I CAN the('66- Monts of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify chat the waste,riilnilnlzation 9 slemeht Identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(If I am a small quantity generator)is true. M nth Da---Year,) <br /> Generator'slOfferor's tintedFiyped Name J Signature t, a <br /> 16,Intemational Shipments F�Import to U.S. ❑Export from U S., �r ort�f entry/exit: <br /> z Transportersignature(for exports only): f <br /> W 17.TranspoRerAckno edgment of Reoeipt of Materials <br /> s r Month} Day Year., <br /> Transporter 1 PrintealI' ed N@me f �P ,• <br /> Signature .% a = <br /> a <br /> gnature 1 Montf4 Day Yegr, <br /> Si <br /> Transporter2Pripled(fyped Name � � �, ., � ,..) � � <br /> 5 1 :-A. ! 7 [ ` <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space 0 Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> U.S.EPA ID Number <br /> 18b,Aitemate Facility(or Generator) <br /> V <br /> U<. Facilitys Phone: Month Day Year <br /> 0 180,Signature of Alternate Facility(or Generator) <br /> J <br /> S219,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal;and recycling systems) <br /> O 1' 2. <br /> 3. 4, <br /> 20,Designated Facility Owner or Operator,Codification of receipt of hazardous materials covered by the manifest except asfided In Item 18e Month Day Year <br /> j Printe[Type Name Signature <br /> TRAI�ISPORTER'S COPY <br /> EPA Form 8700-22(Rev.3-05) Previous editlons'are obsolete. <br />€ <br /> I <br />