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(ForA ed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 " Ut4cR,1fi H p®� Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number JJK 15.Generators Name an> it(ngAddress Generator's Site Address(if different than mailing address) i,, j rGenerator's Phone: 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 3.Designated Facility Name and Site Address U.S.EPA ID Number i Facility's Phone; 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit H1N and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes 1. l4 14.Special Handling Instructions and Additional Information Ili , 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, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. 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. y Year Generator's/Offeror's Printed/Typed Name Signature Month Dar 16.International Shipments ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Transporter signature(for exports only): Date leaving U.S.: 17.Transporter Acknowledgment of Receipt of Materials { {Transporter 1 Printed/Typed Name Signature Month Day YeE r O .. !a cn {Z Transporter 2 PrintedlTyped Name Signature 1 Q 9 Month Day Year l-18.Discrepancy i 18a.Discrepancy Indication Space ❑ Quantity j ty ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: i i'13b.Alternate Facility(or Generator) U.S.EPA ID Number. J1 IFacility's Phone:. 18c.Signature of Alternate Facility(or Generator) Month Day Year Iz 19.Hazardous'Naste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 2. 3• 4. 111 120.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 16a Printed/Typed Name Signature Month Day Year EP\Fcm 3700-22(Rev.3-05) Previous editions are obsolete.