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designed for use on elfte(12-phch)typewriller.) Form Apmvecl.OMB No.2050-W39 <br /> UNIFORM HA7ARDOUS 1 1.Genenator In Number age I of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFE� 342,21680 JJK <br /> i.; ;-'-,�'f!'-�-4 2-"-'�-�-;I-,(- 1 0-1'� <br /> 5.Generators Name and Me"Address GanwaWgSbAddress(Iftiffereat than mailing address) <br /> KA <br /> 17. <br /> 7,Transp <br /> ,"T 2 Company Name U.S.EPA"mber <br /> 8.Designated Facility Name and ShAddress U.S.EPA ID Number <br /> ga. 91b.U.S.DOT Description(Inclucling Proper Shipping Name,Hazard Class,ID Number, 10.Con '11.TOW 12.Wlt <br /> HIM and Packing Group(I any)) 13.Waste Codes <br /> 2. <br /> Uj <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional l*nnertion <br /> | <br /> 33 <br /> 15. GENERATOF?SIOFFEROFVS CERTIFICATION: I hereby declare dmt the contents of this consignment are fully and accurately described aborve by die proper shipping name,and are classified,packaged, <br /> marked and labele#lacarded,and are In all respects In proper condition for transport according to applicable international and naflotial governmental regulabons.11'export shipment and I am the PrimaryExporter,I certify that thq contents of this consignment conform to the terms of the attached EPAAckff*edpent of Consent. - | <br /> I cw*that the waste minimization statement identified In 40 CFR 262.27(a)of I am a large quantity generator)or(b)(IfI am is he. <br /> GaneraWslOffe&s Printedfryped Name Signature Morh Day Year | <br /> M Transporter signature(for exports only): Weaving U.S.: <br /> -iF 17.Transporter AcknowledUrnent of Receipt of Maierials <br /> porter I Prh*drryped Nam Sign Month Day Year <br /> Signature Wnth Day Yew <br /> 18.Discrepancy <br /> 18a..Discrepancy Indic.ad6n Space El Chtantly Typ. 1:1 Residue El Partial Rejection El Full Rejection <br /> Mariffeat Reference Number; <br /> 118b.Ahematelscillity(orGeneratDr) U.S.EPA iD Number <br /> LL- Facin"Phone: <br /> LLj 18c.Signature ofAJtemate Facility(or Generatc� Month Day Year <br /> 19,Hazardous Waste Report Management Method Codes O.e.,codes for hazardou3 waste trestuent disposal,and recycling systems) <br /> LLJ <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous ma"Is cuvered by th9jr-anifest except as noted In Item 18a <br /> ftnted[Tylpfd Name a Sl �onlh Day Yew <br /> Ll <br /> EPA Form 8700-22(Rev.3-05) Previous edifions are obsolete. D E�1 G N AT E D FAC I L IT`V TO 0-S N r:R ATO ri <br /> { <br /> | <br /> | <br /> | <br /> | <br /> ' <br /> ' <br /> | <br />