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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved ON%No 2050-0039 <br /> F15.UNIFORM HAZARDOUS 1.Generator ID Number 2 Page 1 of 3 Emergency Response Phone 9.Manifest Tracking Number <br /> WASTE MANIFEST JJK <br /> Generators Name and Mailing Address �T Generators SiteAddress(if different than mailing address) <br /> Y Dir <br /> -_"T !aC <br /> 1t0tlktAM, C3 !S"46 <br /> Generator's Phone F1341111 <br /> � <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7,Transporter 2 Company Name U.S.EPA ID Number <br /> 8 Designated Facility Name <br /> Site Address U.S.EPA ID Number <br /> .I <br /> r_3fj r. 1.9" 1, <br /> its". Ax Its" <br /> Facility's Phone: �� #— *� <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 14.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group("d any)) No. Type Duaritty Wtivol. <br /> oC 1IM�-tl� WeRtlledettr �s�b l�otf4 ir711 r f t —t <br /> O <br /> w <br /> LU <br /> 2 XIII'm Viil Amp#.tr'ttkms emote wi to tot It <br /> ALoNxtirtant aim l MohrAA) <br /> CD <br /> 3. <br /> 4. <br /> u F ecialtlSO Ir »s1 sand[�IL miatm <br /> " 1) loloo?.WiriMA 1141.1 &s%N(Atffi& t AND 01111IMMA <br /> Ji -on(Y414)624 41"4 angtlttt"me M7fY r <br /> M] -'-#430".t] Al") � <br /> 15. GENERATOR'SIOFFEROR'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 labeiedlplacarded,and are in all respects in proper condifion for transport according to applicable international and national governmental regulations.If extfort 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 certify that the waste minimization statement identified in 40 CFR 262.27(a)i f I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> GeneratorslOfteroes Printed.7yped Name S:gnatum Month Day Year <br /> j 16.International Shipments <br /> F ❑Import to U.S. ❑Export from U.S. Port of entrylexd, <br /> Transporter signature(for exports only), Date leaving <br /> LU 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name 5]nature Month Day Year <br /> A <br /> Q[77��edfryped Name Signature Month Day Year <br /> 18.(Discrepancy <br /> 18a.Discrepancy Indication Space Quantity Type ❑Residue ❑Partial Rejection Fu <br /> +Re ecuon <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> U <br /> rat Facility's Phone: <br /> W 18c Signature of Alternate Facility(of Generator) Month Day Year <br /> a <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i,e.,codes for hazardous waste treatment,disposal,and recycling systems} <br /> 1. 2. 3. 4. <br /> 20,Designated Facility Owner of Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />