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Please print or type. (Form designed for use on elite (12-pitch) typewriter.) Form Approved, OMB No. 2050-0039 <br /> UNIFORM HAZARDOUS Illy&e 948, tor)IMgmer 1 :3 C1 2. Page 1 of 3. .F gen 0?,sT% hone 4. Manifest Tracking Number <br /> WASTE MANIFEST <br /> r 016870187 JJK <br /> 5. Gen�j0rW,NAk and Mailing Address Generators Site Address (if different than mailing address) <br /> Generators Phone: <br /> 6. TraWp901J1-.PWaTYM@,TR0f$ M1n1`4T` I `'r. RIA GIF. E�; U•§ �P( o r'k 7 i +I <br /> 7. Transporter 2 Company Name U.S. EPA ID Number <br /> 8. Dg ignplt f?oiljt f a hair$ i)�A (( ss U.S. EPA ID Number <br /> �<3reyG.tJt3tIl <br /> r-t t',E;+y`1t Nkl'c' {''ft_! EE <br /> I . AY <br /> Facility's Phone: 31 2` ' )2 1' 600 <br /> ga. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Total 12. Unit <br /> HM and Packing Group (if any)) 13. Waste Codes <br /> No. Type Quantity Wt.lvol. <br /> t <br /> W <br /> Z 2. <br /> LLI <br /> 3. <br /> 4. <br /> I <br /> 14. Special Handling Instructions and Additional Information <br /> s; '(1: ,vi, % `s � ? tt' 33 , ! _ f Fri . x s :R OiJt. t <br /> _;�t. a' f f �s �-9�":.�; ft' s i -. " `� ,? t r" s" r' i < �i'i.'�. a ;"` P•;: � 7e� o- a -� i <br /> 15. GENERATOR'S/OFFEROR'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 intemational and national govemmental 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 EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (If I am a small quantity generator) is true. <br /> Generators/Offerors PrintedfTyped Name Signature-. ._ . _ Month Day, Year <br /> r' <br /> —j 16. Intemational Shipments <br /> H ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: <br /> z Transporter signature (for exports only): Date leaving U.S.: <br /> W 17. TransporterAcknowledgment of Receipt of Materials <br /> OTransporter 1 Printedfiyped Name ._ Signature Month Day Year <br /> Q Transporter 2 Pdntedfryped Name Signature Month Day Year <br /> 18. Discrepancy <br /> 18a. Discrepancy Indication Space <br /> Quantity ❑ Type ❑ Residue F71 Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number: <br /> 18b. Alternate Facility (or Generator) U.S. EPA ID Number <br /> J <br /> V <br /> Ua Facility's Phone: <br /> W 18c. Signature of Alternate Facility (or Generator) <br /> f. Month Day Year <br /> a <br /> z <br /> W19. Hazardous Waste Report Management Method Codes (Le', codes for hazardous waste treatment, disposal, and recycling systems) <br /> G 1 2• 3. 4. <br /> 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> MEN <br /> Printedfryped Name Signature Month Day Year <br /> EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. ENER OR ' S INITIAL COPY <br />