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' r <br /> Please print of type.(Form designed for use on eGta(12-pitch)ty ,,b,} Form Approved OMB No 2VJM39 <br /> UNIFORM HAZARDOUS 1 1,Generator ID Number 2 Page I of 3.Ervte gency Response Phase 4.Manifest Tracking Number <br /> WASTE MANIFEST J J K <br /> 5 Generators Name and Mairmg Address Generaor s Site Address(if d fferent than mairrig address; <br /> Generator's Phone <br /> 8.Transporter 1 Compary Nary <br /> US EPA la Number <br /> 7.Transporter 2 Company Name U.S.EPA 10 Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Fara7ity's Phone <br /> ga, N U.S DOT Desciipticn fmduderr Proper 5tuppnrg Nam„ 4aa, Gass ;+rurtta <br /> HM and Packing Group rdanpi 10 Contaurers t1 Tata 12.Unit <br /> 1 No Type Quantity WI.Noi. r3 Wasie res <br /> tY <br /> I <br /> � 2 <br /> C7 <br /> 3 <br /> 4 <br /> 14.Special Handrmg Instmctions and Additlo W Information <br /> d, <br /> 15. GENERATOR'SIOFFEROWS CERTIFICATION:i hereby dedare I ml the contents of this raask3rtmenl are fu8y and a curaldy desmbed above by.the proper stuppirp soma,and are classified,padraged, <br /> marked and labeledlplacarded,and ata in a9 respects In proper condition for transport aamdng to applicable Intematbrial and national tions.Ii <br /> govemmerltal fe9 expos shipment and I am the Primary <br /> F.xprler,I artily g1a1 the contents of tips=tsipnment cordons to the terms of the attached EFAAdcnarledgrnent of Carrsenl r <br /> I certify that Ilse waste RiWmiza6on statement Identlfred In 40 CFR 25227(a)(d 1 am a large quantity generator)or(b)(df am a small quanl3ygeneraI4 tree <br /> GeneraWAK feror s PrfnledlTyped Name Signature Month Day Year <br /> 1 10.Intem bona)Sttgrmertts <br /> E" ❑Impart W u's ❑Export from,S Port of entryrexrt <br /> Transporter sgnature(for exports orgy), Date Leaving U S — — <br /> w 17.TransporterAckr" dgrneril of Receipt of Materials <br /> Transporter 1 Prinle67yped Name <br /> Oa Sgnature Month Day Year <br /> z Transpor er 2 Printed, yped Mame 5gnature <br /> Month Day Year <br /> 1- <br /> 18,Discrepancy <br /> 18a.Dfsrrepanry tndcation Space ❑ Quantity ❑Type <br /> 1:1 Residue ❑Partial Re)edion ❑Fuff Reiectian <br /> Mandest Reference Number. <br /> 1 Sb.Alternate FaaTdlr(or Gerreralar) U.S EPA ID Number <br /> Fadli ,phone, <br /> Lu <br /> 18c-Sgnature of Alternate FadZty(or Generat:r, Month Day Year <br /> Q <br /> Z <br /> w19.Hazardous Waste Report Mwagemerl Method Codes a codes for hazardous waste 1realmer.dispose and r2GyCftng syslemsl <br /> a 1• <br /> 20 Designated Facility D ner or Operator Celt 6a ior afreuct a`haardvts r..at!nus cowered br the manifest ex-epi asrdadc Item 18a <br /> PrntewlypedName Sgeature Mcri$ Day Year <br /> EPA Form 8700-22(Rev.3.05) Previous editions areGosolete 13Egrt FIg7EO FACILITY TO GENERATOR <br />