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r <br /> aJV <br /> print or type.(Form designed for use on el (12-pitch)typewriter.) Form Approveb.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.General x fD Ntuber 2.Page 1 of 3.Emergency Response Phone 4 Manifest Tracking Number <br /> WASTE MANIFEST''`; 1014789140- JJ K <br /> 5-Generators Name and Mailing Address — e„ Generatofs Site Address(if ddfeient than mailing address) <br /> Generator's Phone <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7. ransporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Fadlity Name and Site Address ,,r I , U.S.EPA ID Number <br /> Faalflys Phone: <br /> ga 9b.U.S-DOT Description(including Proper Shipping Name,Hazard Glass,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(d any)) No. Type Quantity Wtivol. 13.Waste Codes <br /> IX <br /> z 2. i <br /> t� <br /> t <br /> I <br /> 3. <br /> 4. <br /> 1 <br /> 14.Special Handling Instructions and Additional Inforr"tion - - - <br /> f: r <br /> 15. GENERATOR'S1oFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping nine,and are classdled,packaged, <br /> marked and labeled(placarded,and are in all r m 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 conterris of this oonsig erd conform tb the terms of the atia0ed EPA Acknowledgment of Consent. <br /> I certify that the waste rruntm'rzation statement id lifted in 40 CFR 26227(a)(ff I am a targe quantity generator)or(b)(Kl am a small quantity generator)is true. <br /> GeneratoeslOfferoes Prirntedayped Name Signature Mooth Day Year <br /> j 16.International Shipments � 1❑. <br /> E— Import to U.S, LJ Export from U.S. Po;rtof�/exit. <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.TransporterAcluwwledgmerd of Receipt of Materials <br /> Transporter 1 Prirnted(Typed Name Signature Month Day Year <br /> a t v <br /> T Transporter 2 PintedrTyped Name Signature Month Day` Year <br /> F <br /> 18.Discrepancy <br /> 18a-Discrepancy Indicafion Space ❑ ❑ ❑Partial Rejection ❑Full Rejection <br /> ❑ Quantity I Type Residue ej <br /> Manifest Reference Number <br /> I— 18b.Altemale Facility(or Generator) U-S.EPA ID Number <br /> U <br /> Fadlity's Phone: <br /> Lu 18c.Signature of Alternate Facility,(or Generator) Month Day Year <br /> a <br /> z <br /> y19.Hazardous Waste Report Management Method Cod (i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator Certification receipt of hazardous materials rbvere_d by the manifest except as noted in Item 18a <br /> Printed(Typed Name Signature ti'' Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Prevjpus edifions are gbsolete. GENERATOR'S INITIAL COPY <br />