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Please print or type,d=orm designed for use on elite(12-p'leh)typewu ter.]: <br /> UNIFORM HAZARDOUS' <br /> n <br /> 1.Geerator Io Numberroved.OMB No.205W9Farm.App <br /> 2 Page Y aP 3.Emergency Resporue Phme 4.Manifest Tmcki� umberN <br /> WASTE MANIFEST (r .4L6 87'989 JJ K <br /> 5"Generators Name and Mailing Address Generator's Sita Address Vdi ferent than mating address) <br /> Generator's Phone: <br /> rFaat/sPhorte: ompompany NameU.5,EPAlD Number <br /> Tdy Name and Site AddressU.S.EPA ID Number <br /> .. <br /> ga. 9b.U.S.OOT Description('rndudmg Proper Shipping Name,Hazard pass !D Number, 10 �� <br /> HM and Padang Group('rf any)) 11-Total 12.Unit 13.Waste Codes <br /> 1 Na. Type Quantity Wvl/d <br /> p - i <br /> LLI <br /> z 2. <br /> 0 <br /> 3. <br /> 4. <br /> 14 Sparta]Handling instructions and Add itianaf Information <br /> Ito &-�l/cQ <br /> 15. GENERATOR'S!I]FFEROR%CERTIFICATION: I hereby declare that the contents of this Q=s nmenl are to y and accuratel described above the <br /> marked and labeledlplacarded,and are in all respects in Proper condition far bansp«t accord to a y sWng name,and are dassrfied,packaged, <br /> Exporter,I certify that the contents of this=*nment conr«m b the tears of the attached EPA ppF,r N Intemati nal and national governmental regulations.Ita1gW shipment and 1 am the Primary <br /> I certify that the waste minimization statement iden%ed in 40 CFR 262.27 a rrf I am a Aty generator) <br /> ant(b Consent <br /> () large quantity genaramr)«{b)(dl am a smau quantity generator)is tare. <br /> GenegatorsUftroes Printedriyped Name Signature <br /> Month Day Year <br /> 16 Interna tonal Shipments <br /> ❑Import to U.S ❑Export i T U S Port of erdryrextt" <br /> Transporter signature(fur exports only): <br /> 17 Trrr w terDate)eaving U.S. <br /> Adorowledgment of Receipt of 6latedals <br /> O Transporter i PrintedlTyped Name S�natcre <br /> CL Month Day-Year <br /> CA <br /> ZTransponer2 dnt ypedName Sx�nahrre ' <br /> + Month Day Ye?r <br /> 18.Drscrepanry V y `' <br /> 18a.Discrepancy Indication Space ❑ r�Quantity �l Ty:r ❑Residue ❑Partial R* n <br /> ❑Ful Rejection <br /> 18b Alternate Facility for Generaar) Manifest Reference Number. <br /> -� U.S.EPA 1D Number <br /> U <br /> L<4 FacE ys Phone: <br /> LU 18c.Signature of Attemate Fadbty(«Generator) <br /> a <br /> Z ti Month ❑ay Year <br /> w19.Hazardous Waste Report Management Method Codes n a codes for hazardous waste treatment dis <br /> G 1 2 pawl,and recycling systems} <br /> 3 4 <br /> 2D Designated Faatity Owner or Operator.Certification of receipt 0hazardous mateials cover-k by-ie manifest except as-ded in Item 16a <br /> rin'111i7yped Name <br /> Signature ��nth Day Year <br /> EPA Form 6700-22(Rev 3-05) Prev'ous editions are ahsoFete. <br /> TRANSPORTER'S COPY <br />