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n-+ r n <br /> ,U 131 U3ID '• U3 �L <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS I'-Generator ID Number 2.Page 1 of 3.Emergency Response Phone r012177654 <br /> anifest Tracking Number <br /> WASTE MANIFEST ��r�a ® - JJ K <br /> at <br /> g Address Generators Site Address(f different than mailing address) <br /> F/'�stA f�7'1, a+, <br /> Generators Phone: r <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> _Z� s <br /> rant ps rter 2 Company Name U.S.EPA ID Number <br /> 8.Qqignated Facili Name a7,ite ddresj, U.S.EPA ID Number <br /> Facility's Phone:s,7-39 /-/11 <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Gass,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(d any)) No. Type Quantity WtNol. <br /> 1 <br /> N <br /> Z 2. <br /> W <br /> 3. <br /> 4. <br /> 14.Special Handling Insons and Additional Info ation <br /> • so l ci '•n tt,1T7%4aC <br /> �irJ U7 <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 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 <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 /> General rs Printed/Typed Name Signa Month Day Year <br /> I <br /> t I ef6 c2167 1 <br /> 16.International Shipmen <br /> i- ❑Import .S. ❑Export from U.S. Port of entry/exit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowled ment of Receipt of Materials <br /> r- Tra porter 1 Pdnted/Type a Sig lure Month Day Year <br /> O <br /> IR -- <br /> a ra sporter 2 rinted/Typ ame Signature Month Day Year <br /> fr <br /> r- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type El Residue El Partial Rejection El Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> Facilitys Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> H19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems)— <br /> UA <br /> ystems)'"`G 1. 2. 3. 4. <br /> \3Z <br /> 20.Designated Facility Owner or 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 /> Y-At, *9u(- 1(.R J(o Ion I I to <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> 12265.1843 <br />