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Please print or type.(Form designed for use on elite(12-pitch)typewriter,) i Form Approved.OMB No.2050-0039,
<br /> UNIFORM HAZARDOUS 1.Generatorsi ID Number 2.Page 1 of 3 Emergeincy Response Phone 4 M fest Tjr�a�r�k�ynq Nu b rye �Jyj�[
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<br /> WASTE MANIFEST.,,' JJK
<br /> 5 Gerterator tyamend Mailing Address Generators SIte7lddress(if different than mailing address)
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<br /> Generators Phone:
<br /> 6.TO 3 1oi:' = as U S EPAJDj�luf be r3€ c ,
<br /> 7.Tran'sporter2 Company Name e, f U S EPA ID Number
<br /> 8.Desrgnated FacHitg ffe and Site Address LAw b' f CP tG 4 jf lw'7$ `r ':."C ? U.S.IEPAA D rnt�er -
<br /> �`'1�ti.:Y,< ,.`Fowi�?�1'�3Q, ��7/?�f.� �':'q'�2'�6xe✓IGC jl�v�r'�,�w'> � �;,
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<br /> Facllitys Phone:
<br /> ga• 9b 11.S.DOT Descnption(including Proper Shipping Name Hazao Class ID Numtier`;; 10 Containers ,y 11 Total i 12 Unit
<br /> HM and Packing Group(Uany)) odes
<br /> :.:_• _._•. _ ...- Np. Type, Quantity MMI.
<br /> 13 Waste C
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<br /> 14.SµpeCraltarldjj�q IngtrucUons and Additional Information
<br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION ?I bereby declare that the contents of,this consignment are fiilly and accurately de cribed,above by the'pro er;'shipping name,and are ciasslfie ♦acka ed
<br /> marked and iabetedtpiacatded and'are in all respects in proper condition;for transp'brt according;to appifcaiiTe ntematwnaFantl nati naf goVemidental re ulations:=Ilex"it"slit meat and I a' 'tl `P" 9
<br /> 9 P� , P m e Pnmary
<br /> contents of this cons€nmem conform to the temie of the attached EPAAcknowietlgmentaf Consent
<br /> lcxporter I certdy that the g
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<br /> lcerity hafthe waste ainimizatiodstatemeht identified IolgCFR 262,27(a)(If I ama;lage quahbty,generatoi)or( aasmah;quantiity generator)is;true;
<br /> Generators/OferorsPnnted/Typdae. r6rr
<br /> 'On nth DBy Yqa
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<br /> —.r 16 InternationatShipments
<br /> zh ❑Import to U.S �iExport frU S,' ' P.ort of entryle>ut
<br /> Transporter signature(for,eports only): * '_.'., D to Ieaying U.S..
<br /> CK 17.Trahsporterftnowiedg' ent of Receipt of Matedais: w�
<br /> aTransporterl Pdnted/Typed _, Signa Month DYea
<br /> Qr,.n,, rtar2PrtntedlTypedNametix Signature { /� :+1 ` C• onto Da Ye�' �. � �(I• _� ' Y
<br /> 18.Discrepancy
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<br /> 18a.Discrepancy Indication SpaceEl Quantity ❑Type. , ❑Residue ❑Partial Rejection ❑Full Rejection '
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<br /> ?61festReference Number:
<br /> 18b.Alternate Facility(or Generator) U,S.EPA ID.Number
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<br /> Facilitys Phone:
<br /> W 18a Signature ofAltemate Facility(or Generator) Month Day Year
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<br /> 19,Hazardous Waste Report Management Method Codes(i.e.,codes for haiardous wastelreatm'snt;disposal,and ecychng systems)
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<br /> 20,Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as Tided in item l8a;
<br /> Printednyped Name t -
<br /> �^� Signature - Month Day Year
<br /> EPA Form 8700-22(Rev.3-05) Previouseditions are'obsolete;` TRANSF'ORTER'S COPY
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