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Please print or ON.(Form designed for use on elite(12-pitch)*awdter.) �� i <br /> i.Generator DNumber Form Approved.OMB ido.245Ckpp39 <br /> UNIFORM HAZARpOUS 2,Page t of r+3�.E�m�ergenc�y}Rasporsse Phone 4.Manifest Tracking Number >i <br /> WASTE M,gNIpE5F C4JG� 5 Mrs � '�y+"f� 7 44.��/ '01-5864520. <br /> 5.Generators Name and Mailing Address t Ir - J J K 3 <br /> t fi Gene s site Address{dcmeereemthan maTng address) <br /> Genera s Phone: <br /> 6,Transporter 1 Company Name <br /> I n U.S!EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Desi rjated facalyName"a¢d.5It�,Address is <br /> U.S.EPA ID Number <br /> I$ ;r FtiC;i 3t71u C�En � �. <br /> Facil s phone: ,�f'm- <br /> 9a. 9b.U.S.DOTDescriptlon[including Proper Shipping Name,Hazard Class,!D Number, 10.Confainers <br /> HM and Pecking Giaup(d any}� 11.,Total .12.Unit <br /> 13.Waste Codes <br /> 1. t fd f FErs nEKl3t7*ir�16'A� &DUE! ,'` LVzolt'2- No. Type, Quantity WL/Vol. <br /> 2 F <br /> LU <br /> 2. � G t, <br /> 3. <br /> 4. <br /> I14. Hand109 Insnctions and Additional Information <br /> i3Tf f7? ITT87 <br /> EC±:7e <br /> _ ill r1.�=�s-fir <br /> 15, UENEitATOit'SfOFFERORIS CERTIFICATION: I hereby declare that the corntents of this 0XLs+gnmen1 are fully and accurately descrr'bed above by the proper shipping name,and are classified,packaged. <br /> marked and labeted*carded,and are kr al respect Ln proper mndkn for transport according to appkabie it temational and national gavemmentat 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 EPAAcknavledgment of Consent. <br /> 1 codify that the waste minimization statement identified in 4g CFR 26227(a {d I am a large quantity generator Or(b) <br /> Generdwr'sfOfferors PdntedlTyped Name @} am a small quantity 9eneraar}is tore. <br /> —� S+gnature Month ay Year <br /> -J 16.IntamationalShipments 1 I r <br /> Transporter signature(for exports mly�Impart to U.S ❑Export from U.S Port of entrylexit <br /> 17.TransparWArknonvledgmenl of Receipt of hlaterfals Date leaving U.S.: <br /> Tia YPed -ame. <br /> NC l signatureMonth Da <br /> 1 r Y Year <br /> ranspoter 2 Q rhdt&'ryped Name f,Signature <br /> Month Day Year <br /> 19.Discrepancy <br /> 18a.Discrepancy indication Space <br /> D Quantity Type ❑Residua ❑Partial Re <br /> )action ❑Fu!!Rejection <br /> 16b.Attemate Faci!--ty r. <br /> V <br /> U.S.EPA t0 Number <br /> Facifl y's Phone. <br /> 18C.Signature of Aftemate Faci dY(ar Generator) <br /> x Month Day Year <br /> 19.Hazardous Waste Report -------- <br /> LLJ <br /> 1. Methd C2 dm , <br /> Y ;system7 /j, <br /> ifC/) 3 4. <br /> 24.Designated Fac y Ownei or Operator.Certification of receipt of hazardous matQdals covered by the manifest except as noted in Item 1 sa <br /> Name � <br /> i. <br /> k ( Signa ,l Month <br /> �- / ..ay Year <br /> EPA Form 8700-22 iRev."z)) Previous emons are obsolete. r : ' `" • 7 r;" <br /> r i /TRANSPORTER'S COPY <br />