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Please print or type,(Form designed for use on elite(12=pitch)typewriter.). <br /> UNIFORM N 1.Generator ID Number Form Approved.OMB No.2050-0039 <br /> AZARDOUS 2.Page 1 of 3.Emergency Response Phone Manifest Traddng Number <br /> WASTE MANIFEST JJ K <br /> 5.Generator's Name and MaWng Mdress -i ": i x►t + o <br /> Generators Site Address(if different than mating address) <br /> Generators Phone: <br /> 6.Transporter 1 Company Name <br /> U.S.EPA ID Number <br /> 7.Tmnaporter 2 Company Name <br /> U.S.EPA ID Number <br /> B.Dealgnaled Fadilty Name and Site Address <br /> U.S.EPA ID Number <br /> Facility'a Phone: <br /> ga. 9b.U.S.DOT DescriptionInduct <br /> ( in9 Proper Pa Shipping Name,Hazard Class,ID Number, 10Centel are HM and Pack'ng Group(if any)) . 11.Total 12.Unit 13.Waste Codes <br /> 1. <br /> No. Type Quantity Wt.Nol. <br /> Z 2... ..LU <br /> _ r <br /> FAL i� Y LIN 'St-AIR`�' 0�ACIIf TY,EPA _ t <br /> 3. <br /> 1 <br /> AND WILList ,,:t . Niv WAS(E AS QU`F'PEP <br /> 4. j <br /> 14.Spedal Handling Instruct and Additional Information <br /> r <br /> ' I <br /> 15, GENERATOR'SlOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shlpping name,and are classified,packaged, <br /> marked and labaledrplacarded,and are in all respects in proper condition for transport according to applicable International and national govemmental regulatlons.If export shipment and I am the Primary <br /> Exporter,I certify thal.the t6n6e iir f this consignment conform to the terms of the attached EPAAcknowladgment of Consent,....- <br /> I certify thatlheviiito momiU"Uon statement Identified In 40 CFR 262.27(a)(If I am a large quantity generator)or(b)(ill arri a small quantity generator)Is true. <br /> Generatcrsl0tleroes P' a!Typed Name ..,• <br /> K'' i_-,- .! Signature Month Day Year <br /> -1 16.International S pments r 1 <br /> mp3. ❑FxpoA•f�aifU.3. Portojentry]etdt <br /> Transporter slgneture(forr expefls only): ['J6(l laaWtp U.3.; <br /> w 17.Transporter A¢ dgmert of Receipt of Materials f <br /> Transprfer Printedrryped Name t <br /> Signature <br /> a I ( `% f! { Month Day Year <br /> y. F J 1 <br /> t I{_. <br /> Q Transporter 2 Prinlp5yped Name <br /> Month Day Year <br /> F- <br /> 18.Discrepancy <br /> 18e.Discrepancy Indication Space Quantity ❑T <br /> YPe El Residue El Partial Rejection ❑Full ReJecBon <br /> Man fest <br /> 18b.Alternate Facility(or Generator) Reference Number. U.S,EPA ID Number <br /> J <br /> U <br /> LL FadliVs Phone: <br /> w 18c.Signature ofAHemale Faciiy(or Generamr) <br /> Q Month-Dayy., <br /> z � <br /> 1g.Hazardous Waste Report Management Method Codes(Le.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> w 1 <br /> 114t_� 2 �}� <br /> 20.Designatad Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 198 <br /> Printed/Typed Name I1 i, <br /> `i l r ! +} % Sl9rreart� 1 f 1 Mo th -Pay Year <br /> _ �) r.i �( lam. ` ! 1''1 .� 'r9 r t�`•, <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> DESIGNATED FACILITY TO GENERATOr <br />