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Please riot or t ' <br /> p type {Form designed For use on elite X12-pitch)typewriter) Form Approved,OMB No.2050-0035,UNIFORM HAZARDOUS 1 Generator ID Number 2 Page i of 3 Emergency Response Phone 4.Manifest Trucking Number <br /> WASTE MANIFEST 0110-8648-5-7 <br /> 1 18 6 4 8- 7 J J K <br /> 5 Generators Name and MaZ g Addres3 Generators Sate Address(if different than mawng address) <br /> Generators Phone: <br /> 6.Transporter 1 Company Name <br /> US EPA ID Number <br /> 7 ransporter 2 Company Name <br /> U.S EPA 1DNumber <br /> 8.Designated Facility Name and Sits Address <br /> U.S.EPA ID Number <br /> Faa,-tys Phone <br /> 9a, 9b US DOT Description(rndw&,g Proper Shippmg Na-le. iazard Claes 'D Num:-rr, 1D Containers <br /> HM and Packing Group(if any)) 11.Total 12 Un t 13 Waste Codes <br /> No, Type Quantity WtAal <br /> W <br /> aO <br /> W + <br /> a 2. <br /> Lu <br /> C7 <br /> 3, <br /> 4 <br /> 14.Special Handling Instructions and Additional information <br /> - 37'1 <br /> 15. GENERATOR'510FFEROR'S CERTIFICATION.-I hereby dedare that the contents of this consignment are fully and accurate y described above by the <br /> marked and labeled/placarded.and are In an respects in proper condit'on for transport according to appr�intemationa and national governmental reguiaptions.I pexport shipment and f am the and are classified,packaged, <br /> Primary <br /> E iter,l certify that the contents of this confgnment conform to the terms of the attached EPAAcknowledgment of consent <br /> Ice*that the waste minimization statement identified in 40 CFR 262.27,a)(N I am a large quantity generator)or(bj(Wo am a sma7 quantity generator)is true, <br /> Generatorsl0fi'erors PriptadlTypad Name 5igr asure f l <br /> It Month Day Year <br /> T Intsmabortal Shipments <br /> ❑Import to U.S ❑Export from UrS Port of enWexlt <br /> Transporter signature(for exports only), <br /> 17 TmnsportwAdmowledgmerrt of Receipt of Materials Data-javing U.S,: <br /> cc: Transporter tPr nWVyperJlrame ((�� Signature lI <br /> y 4 . .� +L / 1111 Month Day Year <br /> Transporter 2 PrinWiffyped Name <br /> Month Day Year <br /> 18.Discrepancy <br /> 18a,Discrepancy Indication Spacef•--1 <br /> ❑ Quan'-r L�jyp, ❑Residue <br /> Partial Rejection ❑Fu Refection <br /> LFadiflys <br /> zmate FaG7ty or Generator; Manifest Reference Number. <br /> U.S.EPA ID Number <br /> Ci <br /> Phone:ignature of Altemate Facility tar Generemr) <br /> Month Day Year <br /> 19 Hazardous Waste Report Management Method Codes;l 9.codes for'iazardous waste treatment,d,sposal,and.bre l.,g sys'ems; <br /> 0 1 2 3 <br /> a. <br /> 20.Designated Famnity Owner a Qperator Certification of rete:pt of hazardous maieia3 covered by the manifest except as nded morn+8a <br /> ted/]'yped Name <br /> 56gna ure Month Day Year <br /> EPA Form 8700-22(Rev 3-051 Previous editions are Dbsalete <br /> TRANSPORTER'S COPY <br />