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<br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) ; �i> I ,�J t ^dr ,'Irl li'iltiJ Form Approved.OMB No.2050039.
<br /> 1.GeneratorlD Number f± 2 Page 1.of 3 Emergency Response Phone 4 Ma T k�0 N r640 UNIFORM HA2ARd0U3 3 t Ct1 4r�^ + i.lrlt "or"i:r!(tlr>r`t r `� 'r 4 +�1�
<br /> WASTE MANIFEST'1141'
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<br /> HM and Pa in Grou if an " F.f 13.-Waste Codes
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<br /> 14. 4aILJar dhng ljVWctions and Additional I formation
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<br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION '1!bereb'declare tha�t�ie'contenI of this co Isignttient arerfUlly antl accurately de tdbetl above bythe'proper;shipping name and are classfienk packaged,
<br /> marked and la6eiedlplecarded,and are'in all'respecfs,in prop or;condition.fo transport acco�ling;to applfcabl•'d•lhiemational'hd nationel(govbmrriental regulations�If'ezportshipment antl l am the Ptlmary!
<br /> Exporter I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgm@nt of Consent ;. .
<br /> I certify t8et'tne waste minim izadon'statemenHdentified in 40 CFR 262 27(a)"if I am a large+quaritily ge'ner tor)or'(b)(If I nit)a smah quaff ity'generator)is true;; ;
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<br /> 16 International Shipments
<br /> �- a ❑Import to U.S, ❑Export fro U Port of enirylezit
<br /> z Trenstiorter signature(for exports only):; ; ; b'te Ieving.0;S.
<br /> W 17.TranstiorterAcknowlad 'ent of Receipt of Matedats r,
<br /> Trahsporter 1 Pdnted/Typed a e Signa S Month D Yaa
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<br /> z TransporYgr 2 Pd tedlrTyped Name ti Signature. F, ,� •1, ' 'o on�b ' Day' Year;'•
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<br /> 18.Discrepancy �•.
<br /> 18a;Discrepano.yIndication Space
<br /> Quantity ❑Type ❑Residue Partial Rejection ❑Full Rejection
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<br /> " ManifestReference•Ntimb'an
<br /> 18b;Aitemate Facility(or Generator) U EPA;ID Number
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<br /> W Facility's Phone:,; b,-
<br /> W 18c:Signature of Altemate Facility(or Generator) Month Day Year
<br /> 19.Hazardous Waste Report Me agement Method Codes(Le.;codes for hazardous waste treatment,;dJsposal,and recycling systems) ,
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<br /> 20,Designated FacultyOwner or,Operator,;GerBficaUon of'iecelptof h'' Mops mateitels coveFed,by thermedifest ezcapt'as'natetl in'Ifem,18a.#,
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<br /> EPA Form 6700.22(Rev,3.05).Previous'.editlons are+obsolete.{' TRANS.PORTER'S COPY
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