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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) ��Forrn Ar.drovecr OMB No.2050-0039
<br /> UNIFORM HAZARDOUS 1.Generator ID Number 2,Page 1 of 3,Emergency Response Phone 4,Manifest Tracking Number
<br /> WASTEMANIFEST e . . '� G-. ' Yr t`>�A` ")y 01478331 4 JJ K u
<br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address)
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<br /> Generatorts' �iohe ,-'�...�•. �°�w,� r�, .�. �'
<br /> G Transporter1'Company Name U;S EPA1D Number
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<br /> 7.Transporter 2 Company Name U.S.EPA ID Number
<br /> 8.Designated Faclli�Name and Site Address U.S.EPA ID Number
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<br /> Facility's Phone:
<br /> ga 9b.U.S.DDT Description(Including Proper Shipping Name,I-hod.Class,ID Number, 10 ContainTotal
<br /> ers; 11. ;;, ,12,Unit- 13 Waste Codes
<br /> HM and Packing Group(if any)) No: Type Quantity, Wt,Nol.
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<br /> 14.Special Handling Instructions and Additional Information
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<br /> 15. GENERATOR'SIOFFEROR'S 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 governmental regulations.If export shipment and I am the Primary
<br /> Exporter,l certify that the contents of this consignment conform to the terns of the attached EPAAcknowledgment of Consent`
<br /> I certify that the waste minimisation statement Identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(If(ar,$a small quantity generator)Is true.
<br /> GenJee�jr@a��t_o_,,r Offe o s Pnnted/ryped Name Signa ure Month Day Year
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<br /> � 16.International Shipments"
<br /> t— ❑Import to U.S. ❑Export from&U,S,;� Port of entry/exit:
<br /> Transporter signature(for exports only): Date leaving U.S.:
<br /> IX 17,Transporter Acknowledgment of Receipt of Materials
<br /> Transporter 1 Printed/Typed Narge,-^^"'"j( Signati)?0 1. J f Month Da�yy Year
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<br /> QTransporter 2 Pnntedrryped Name r "°"' Qtoature,"° s :" ..# Month ..'Day Year
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<br /> 18.Discrepancy,
<br /> 18a,Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue
<br /> ❑Parfiaf Rejection ❑Full Rejection
<br /> Manifest Reference Number:
<br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number
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<br /> L¢+. Facility's Phone:
<br /> 18c.Signature of Altemate Facility(or Generator) Month Day Year
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<br /> N19.Hazardous Waste port Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems)
<br /> 01. 2, 1 3, 4.
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<br /> 20.Designated Facility Owner'or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a
<br /> P ntedrryped Name ' Signature Y Month Day Year
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<br /> EPA Form 8.700.22(Rev-1-05) Previous editions are obsolefe, l 4 TRANSPORTEWS COPY
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