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Please prini or type,(Farm desi rted fur use on este{12-pitch}typewriter.) <br /> UNIFORM HAZARDOUS 1 Generator IU Number 2.Page i of 3.EineForm Apved t7M8 Na,2050 OQ39 <br /> WASTE MANIFEST rgertry Response Phone �1-1�11nlostTr,�cklngl�orr' <br /> 5.Generator's Name and MaungAddrem Generator's Site Address(f different than mailing address) J J K <br /> Generatoes Phone <br /> 6 Transporter 1 Company Name <br /> -US EPA i D Number <br /> 7 Transporter 2 Company Name <br /> U 5 EPA IU Number <br /> a Designated Fadtity Name and SiteAddresx <br /> U.S.EPA ID Number <br /> Faalirys Phone <br /> 9a. 9b,U.S DOT Description(including Proper SNppmg Name,Hazard Class,ID Number, <br /> HM and Packing Group(if any)) 10 Containers 11 Total 12 Unit <br /> s No Type Quantity WLNo 13 Waste Codes <br /> aO <br /> flC <br /> W <br /> W <br /> 3 <br /> 4 <br /> 14.Specht Hama g Inslrudiorts and Additional information <br /> 15. GEN ERA TOR'SlOFFEROR'S CERTIFICATION:I hereby declare that the contents of Ibis <br /> marked and laberedfplacarded,and are in all respects in proper condition for cdlin to applicable <br /> are llyint and accaaatety descnbed above by the proper shipping name,and ere classilEed packaged, <br /> Exporter,I certify that the contents of Hits oomsigmmtent conform to the terms off pqA intemalionaland national govemmmtal regt�ations.If export shipment and I am the Primary <br /> I certify that the waste minimization ptatemenl Identified in 40 CFR 26227 a if 1 am a eagment of Consent. <br /> ( 1( large quantity generator)or{b}(HI am a smart quantity generator)is true. <br /> GeneratarslOHeror's PrintedlTyped Name 5 azure <br /> A Month Day Year <br /> FJ- 16.kttematanal Siupmenls <br /> I- Elimport to U.S. Eapat from U.S Port of entrylexit: <br /> Transporter signature(for exports only): <br /> IX Dai)covin U.S.: <br /> 17.7ransporter men)of R 9 <br /> rti e'd9 eceipl of Materials <br /> Transporter 1 PnmedrTyped Name <br /> 0. z Signature Month Day Yew <br /> Q Transporter 2 Pdntedffyped Name <br /> Signature <br /> P5 Month Day Year <br /> 1&.Disczepanty <br /> 18a.Discrepancy Indiplian Space <br /> ❑ Ouantly ❑Type ❑Residue ❑Partial Rejection ❑Full Resection <br /> 18b Alternate Fadf ry(ar GeneralarJ Manifest Reference Number. <br /> V <br /> U.S EPA ID Numtber <br /> L* FaaWs Phone: <br /> Lu 1&.Signature orAnemate Facility(or Generator] <br /> Q Month Day Yeti• <br /> x <br /> 19.Hazardous Waste Report Management Method Codes(i.e,.codes for hazardous was <br /> LU 1 le treaMent disposal and recycling systems) <br /> A 2. 3 4 <br /> 24.Designated Faol,ty Owner or Operator Ceri,5cation of rete pi or hazardous matenals covered by the manifest except as noted m tem 1 as <br /> PdntedlTyped Name <br /> Signature Month Day Ye_ <br /> EPA Form 8700-2Z(Rev.3-05) Previous editions are obsolete. <br /> DESIGNAiEG FA. ILITY T;' <br />