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Please print of type (Farm designed for use on elite(12-pitch)typewriter) Farm Approved t?Mt3 No 2050 0039 <br /> UNIFORM HAZARDOUS I.GeneratarFD Number 2 Page i of 3,Emergency Response Phare 4.Manliest Tracking Number <br /> WASTE MANIFEST JJ K <br /> 5,Generators Name and Mang Address Generators Site Address(d different than mailing address) <br /> Generator's Phone: <br /> 6 Transporter 1 Company Name <br /> U.S EPA ID Number <br /> 7 Transporter 2 Company name <br /> U.S.EPA ID Number <br /> 8 Des$gnated Faallty Name and 5 to Address <br /> U.S.EPA ID Number <br /> Facility's Phone <br /> ga 9b U S DDT Desaoon linduding Proper Shipping Name,Hazard Class.10 Number 10.Containers <br /> HM and Packing Group fdany;) 11 Total 12 Unit 13 Waste Codes <br /> 1 <br /> No Type Quantity wuvd <br /> rr <br /> O <br /> W <br /> W 2 <br /> 3 <br /> 4 <br /> 14 Spedal Handling Insfrudians and Additroro Information <br /> 15 GENERATGR'SfOFFERGR'S CERTIFICATION-I hereby declare that the contents offt canslglumi are fully and accuratelydescribed above the <br /> marked and labeledfplacarded,and are in all respects in by gu per shipping name,and are dassi6ed,packaged. <br /> Pett Proper condition for transport aocordmg W applicable international and national gwemrttental regulations.tf export shipment and i am the Primary <br /> Exporter,l certify that the comien;s of this consignment conform to the terms of the attached EPA Acknowledgment of Consent <br /> 'certify that the waste minim ton statement identified`n 40 CFR 262.27(a)(if I am a targe quantity generator)or(b)(if I am a small quantilygenerator)is true. <br /> Generalarsr(lffemes Pnnteti✓Typed Name 54nature <br /> Month Day Year <br /> F 16 International Shipments <br /> ❑1 mpat to U s ❑Export from nalure(hu rg U.S. Port of entry+exit: <br /> 2 Transporter s' exports oruy)� <br /> 17 Trargxxter Ar waMedgrneni of Receipt of Materials Date leaving U.S.: <br /> GTransporter 1 PrintedlTyped Name Sgcakire <br /> CL Month Day Year <br /> Cn <br /> Z Transporter 2 PmtedlTyped Name Signature <br /> Month Day Year <br /> 18.Discrepancy <br /> 18a Dtwepancy indication Space ❑ QuanBty <br /> ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> lab.Alternate Fao5ity(or Generator) Marrfesl Reference Number. <br /> U.S.EPA ID Number <br /> FacMys Ptrone' <br /> 18c,Signature of Alternate FaaGry(or Ge^ereton <br /> Q Month Day Year <br /> Z <br /> ca <br /> Ig Hazardous Waste Report Management Me thud Codes,i a codes for hazardous vresle treatment disposal,andm9 systems) <br /> el t 2 3. 4 <br /> 20 Des grated Fa:iitr-Owner 46r Qotra!or cerGfiraeon of receipt of hazardous materlAs covered by the manifest exrept as noted in Ikm 18a <br /> PrntedlfypW Name Signature <br /> Month Day Year <br /> EPA Form 8700.22(Rev.345) Previous editions are obsolete. <br /> DESIGNATED FACILITY TO GENERATDR <br />