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Fiem print or type.(Form designed for use on elite(12-pitch)typewriter) <br /> UNIFORM HAZARDOUS 1.Generator lD Number T��7 <br /> ergen R Funm Appmed OMB No.2t75MG39 <br /> WASTE MANIFESTon�Phono A.lRani[esi Tracking Number <br /> S.Genera!or s Name and Mat ng Address <br /> Generator's Site Address{if different than mating address; J J K <br /> Genera&s Phone, <br /> 6.Transporter 1 Company Name <br /> U$ETA—0 N.mber <br /> 7 Transporler 2 Company Name <br /> U5 EPA i0 Number <br /> B.Desrgnated Faabty Name and S8e Address <br /> U S.EPA ID Number <br /> FacIty's Phone• <br /> ga, gb U S DOT Descxiiption(induding Proper Shipping Name Hazard Class ID Number 10 Con'aner <br /> HM and Pa-king Group{i any)} 11.T=1a! 12 Unit 13 Waste Codes <br /> 1 No. Type Quantity Wtilm <br /> rr <br /> � w <br /> w <br /> uzi ` <br /> c7 <br /> a <br /> 14.Special Handling InstmcGans and Additional infemratian <br /> 15 GENERATOR'SlOFFEROR'S C9TIFICA110N.r hereby declare tt2t the contents of this omsignrnent are <br /> My and accurately desc&ed marked ander e&pIa;&rdmI,and that ifs of re i al respects in proper corditn for transport accadng 10 appkable ntemallonal and tional govern v enllal reguratlons.I y the <br /> Proper sh�name,meand are doss the P�9� <br /> Exporter,t consignmeril conform Io the terms of the attadred EPAAdmmMedgment of Consent export sftipvnenl and I am the Primary <br /> I certify that the waste minimtration statement identified in 43 CFR 26227(a)(d I am a large gtrarttity generator)or(b)(d I am a small qua&y ganeratod is true. <br /> Gen eratoesr0iferces PrmiedrfypedName Signature <br /> Month Jay Year <br /> —1 In 'Mal Shlpment5 r - <br /> 2 ❑Impart to U.S ❑Export from U S. Port of enlry+esk <br /> Transporter signature(forexpars only: Date leaving U S <br /> UW 17.Transporter� po Aclmowtedgment of Receipt of fAatersats <br /> Trarsmrer-PrNar-,e <br /> Mori Dar Year, <br /> rn <br /> Q Transponer 2 Prirted,Tyced Name <br /> Signature Month Day Year <br /> 16 C-saepancy <br /> 18a.firsaEpar,W Indicator Sparc <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> t 9b.A e.:a:e=aunty or ,Senerator, ManNest Raferenae Number <br /> US EPA'DNumher <br /> t1 <br /> u< Facilty's Phone: <br /> 1Bc.Signature cfAitemate Faal:tr tar Generator, <br /> Q anth Day Year <br /> 2 <br /> 19 ra:ardous Waste Report Maragerneat Method Codes i e codes for hazardous waste treasment,disposal,and reoyding systems, <br /> 2.p 1. <br /> 3. 4 <br /> 2D.Designated Facility Owner cc Operator Certi6catiort of receipt of hazardous materials Covered by the manifesl except as nded in Item 1 Ba <br /> Prin yped Name <br /> 5igmanure <br /> ,th Year <br /> ERA Fpm 8700-22(Rev 3-05) Previous edtions are obsolete <br /> DESIGNATED FACILITY TO GENERATOR <br />