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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) ¢ Form Approved.OMB o.2050 OQ39`n <br /> UNIFORM HAZARDOUS 1•Generator'ID Number 2 page 1-0f, 3 Emergency Response Phone 4,Mani est Tracking Number A,+ <br /> r. 0 > <br /> JJK.. <br /> WASTE MANIFEST <br /> H Address ( a ent than mailing address) <br /> 5 Gpnerator� ame aid�laliirtg s , Generators Site Addroks rf differ <br /> Generators Phone: 'r U S:EPA IDNumber <br /> 6.Transporter 1:Company Name v <br /> ; <br /> U.S;EPA ID Number <br /> 7.Transporter 2 company Name <br /> U.S.EPA ID Number <br /> 8,Deslgt+ated,Faciilty,Name and,Slte•Address <br /> d11 <br /> Facility s Phone <br /> ` 10 COhtaine 1 „Total 12 Unit <br /> ga 9b.U.S DOT Description(Including Proper Shipping Name,,�aiatrj Class ID Npmber r �, 13.Waste Codes <br /> " e Quantity WtJVoI. <br /> HM and Packing Group(if any)) No Typ <br /> , , 4} <br /> � f<z +�I' riH„• <br /> r3:•,�17,�• , it i i I.p IG 4 �},`�w� <br /> 10 <br /> •1 , !.it ,ll I.J:.t 1.111 tl„ '�' ,iiiM !f , <br /> W <br /> 2. <br /> 3. <br /> 4. <br /> 14,Special Handling Instructions and Additional Information <br /> 15. GENERATORVOFFEROR'S CERTIFICATION:.I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for_transport according to applicable intemafional.aod nafional governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA'Acknowledgment of Consent. <br /> I cen(ty that the waste minimization statement identified in 40 CFR 262,27(6)(if I am a large quentity generator)or,(b)(if I'am a small quantity generator)Js.true. <br /> Year <br /> Signature ' }' / Mo Da r, <br /> Generatoes10(f�Sofs rintedflype8 Na e P f r i rti <br /> 16.Intemationai Shipments Q Import to U.S: ❑Export from U.S: Port of entrylexlt: <br /> F' Date leaving'U.S <br /> Z Transporter signature(for exports,oniy): <br /> LO: 17.TransporterAcknowledgment of Receipt of Materials <br /> Transporter 1 Printe pe Name / Signature ., r r �; Month ear,, <br /> f ' �' <br /> QTransporter 2 PrintedlTyped Name Signature Month Day Year <br /> H <br /> 18,Discrepancy <br /> 18a.Discrepancy Indication Space Quantity QType Residue ❑Parllal Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S;'EPA ID Number <br /> J <br /> uQ Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> N 19.Hazardous Waste Report Management Method Codes(Le.;codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1 3. <br /> 20.Designated Facility Owner or Operator.Certification of receipt ofhazardous materials covered by the manife'stexcdp,r s noted m Ikgm 18a l <br /> Printedlyp�e'y Name �, 1 f� Month Day Years <br /> j 4 4 r•.. <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. ”' �; TRANSPORTER'S COPY <br /> i <br /> i <br />