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r <br /> Please print or type.(Form designed for use on elite.(12-pitch)typewriter.) Form Approved. <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3 Emergency Response Phone 4.Manifest Tracking Number '• , <br /> WASTE MANIFEST 47A Z' <br /> 5.Generator's Name and Mailing AddressGenerator's Site Address(if different than mailing address) ce M,r <br /> rJ t" ;'r :} `°t .. '.". .; "; S✓, '7 l, a, i.� , '-�<. - y..•t:"x1d f x.: <br /> E <br /> Generator's Phone; <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 CompangName. U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address: U.S.EPATD Number <br /> .. <br /> Facility's Phone <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,JD Number, 10.Containers11.Tolat A2:Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> Z 2. t <br /> w I <br /> ( t <br /> 4. , <br /> 14 Speaat-1490 ng Insbuctionsandsdditnal Information t s € <br /> 15. GENERATOR'910FFEROR 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 IabeTed/piarxrded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.if export shipment and t am the Primary <br /> Exporter Of ee*_tliat the wntents of this consignment conform to'the terms of the attached EPAAcknowiedgment of Consent. <br /> I certifythat the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(h)(ifI am asmall quantity generator)is true. <br /> Generator's/ s Pinted/Typed;Name Signature Month Day Year <br /> ri 16.in ational'Shipments <br /> F— ❑Import to U.S. ❑Export from U.S. Port of entrylexit <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.TransporterAcknowledgment of Receipt of Materials <br /> Transporter 1 Pnnted(Typed-Name Signature f ! Month Day Year <br /> Z Transporter 2 PnntedtTyped Name Signature Month Day Year <br /> 18.Discrepancy <br /> Quanti <br /> ❑ ElP <br /> Type ❑Residue ❑Partial Rejection ) <br /> 18a.Discrepancy Indication Space Quantity ❑Fuli Rejection <br /> Manifest Reference Number. <br /> 18b:Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> uQ. Facility's Phone: <br /> LL, 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <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 or Operator:Certificatlon of receipt.of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature Month Day yede , <br /> w <br /> EPAFonn 8700-22(Rev 3-05)PFevious editions are obsolete. DESIGNATED FACILITY'S GOPY,. <br />