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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved,OMB No.2050-0939 <br /> UNIFORM HAZARDOUS Generator 0 <br /> 1. ,or ID Number 2.Page 1 of 3.Emergency Response Phone 4,Manifest Tracking.Numbe JJK <br /> WASTE MANIFEST 2 <br /> 5,Ge Npfqe ay Mailing Address Generator's Site Address(if different than mailing address) <br /> Generators Phone: <br /> 6,Transporter 1,Com al Name U.S.EPA ID Nun <br /> lber <br /> 7,Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Des �te U.S.EPA ID Number. <br /> I 199V;FOil�,N'9 M,et T-O.k t,�Vfq'?'�i <br /> Facility's- Phone: <br /> ge, 9b.U.S.D&Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> 0 <br /> 2. <br /> UJ <br /> LD <br /> 3. <br /> 4, <br /> 14.Special Handling Instructions and Additional Information <br /> .4 <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 aridlaWled/plabard6d,and 6ra'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,I certify that the contents ol"thili consignment confbirm to the terms of the attached EFAAcknowledgment of Consent, <br /> I certify th ',th'- <br /> at 6,Wsie'minimliation statement Identified In 40 CFR 262,27(a)(if I am a large quantity generator)or(b)(If I am a small quantity g9nerator)Is true. <br /> Generators/Offeroes,Pdnted yped Name Signaturerilh Say Year <br /> -J 16,International ShipmentsD Export from Port of entrylexit:J <br /> F— D import to U.S. <br /> Transporter signature(for exports only); Date leaving U.S,: <br /> LW 17.Transporter Acknowledgment of Receipt of Materials <br /> Transpo 90 rinteclfTyge�NameSignature Month Day Year <br /> 0 <br /> Transporter 2 Printed/Typed Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space El Quantity El Type El ResidueElPartial Rejection El Full Rejectkin <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U,S.EPA ID Number <br /> Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Z <br /> 0 <br /> US 19.Hazard9us Waste Report Management Method Codes(!,a.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU <br /> 2. 3. <br /> T <br /> 2.0,'Designated Facility Ownorgr Ope*p"tor:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> 7 1 P te Signature Month Py Year <br /> �h <br /> ,yped Nam6 <br /> EPA Form 8700-22(Rev.3.05) Previous editions are obsolete. TRANSPORTER'S COPY <br />