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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 1 Generalor ID Number 2 Page 1 of 31 Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST JJ K <br /> 5 Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Generator's Phone <br /> 6 Transporter 1 Company Name US EPA ID Number <br /> 7 Transporter 2 Company Name US EPA ID Number <br /> 8 Designated Facility Name and Site Address US EPA M Number <br /> t4i a1$ 5RL*f4W-.F V,f r€ <br /> FaciGtysPhone. <br /> 9a 9b US 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 Wi.Nol. <br /> 1 1 t <br /> 1 t f+ k1t Y �3i7�f° fi <br /> : TT Ji cufP:.y. r. ; <br /> u.r <br /> 2. I <br /> � r <br /> r <br /> 3 <br /> p <br /> 4 Hod <br /> Retain for 3 ye rs from <br /> 14 Special Handling Instructions and Additional Informefion <br /> ePGO 1? ��1/9.�tiy date. <br /> t IR[✓E�$b to w v;,�::;; �, g�4 <br /> 15 GENERATOR'SIOFPEROR'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 condrhon 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 oonsignmentconform 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)(rfi am a small quantify generator)is true <br /> Generator's10(ffbr's 'nted7yped Name Signatalr Month Day Year <br /> 16-International Shipments <br /> f- ❑Import to U.S ❑Expert from U.S Port of entrylexit <br /> Transporter nature(for its on) <br /> po � xpo Y) Date leaving U.S. <br /> 17 Transporter Acknowledgment of Receipt of,Matenals <br /> Transporter i Printed/Typed Name �f SignMonth Day Year <br /> ZTransporter 2 Printedffyped Name — 9ign&tuse - — Morrth Day Year <br /> F- <br /> 18.Discrepancy <br /> 18a Discrepancy Indication Space ❑partial Rejection❑ Quantity ❑Type El Residue i EJ Full Rejection <br /> Manifest Reference Number, <br /> IZ 18b-AdfemateFacility(or Generator) U.S EPAIDNumber <br /> i Facility's Phone. J <br /> LOU 180.Signature ofAttemate 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 /> B 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 /> PrintednT psd Name '., Signature A Month Day Year <br /> EPA Form 8700-22(Rev 3-05) Previous editions raabsolete D&18NATErD FACILITY To GENERATOR <br />