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Please print or type. (Form designed for use on elite (12-Pilch) typevrtilec) <br /> Form Approved, OMB No. 2050 OD39 <br /> UNIFORM HAZARDOUS 1. Generator lD Number 2. Pagelof 3. Emergency Response Phone 4, Manifest Traohing Number <br /> WASTE MANIFEST pill I . ,: .:a ': -. ri . ; .:, il 'id JJK <br /> 5, Generator's Name and Melling Address Genemlofs Site Address (Ndifferent Own matting address) <br /> Generator's Phone: Z2 . . ._ . _ Tr a(':. " '!'? air! <br /> 0. Transporter 1 Company Name U.S. EPAID Number <br /> To I <br /> 7. Tifnspomer2 Com l ny Name US. EPA IO Number <br /> e. Designated Faculty Name and She Address U.S. EPA ID Number <br /> Focht 'a Phone: - ' � " - "' " ` " " � " `" ' ' ' <br /> ga• 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, IO. Conlalnam 11. Tolel 12. Unit 13. Waste Codes <br /> HM and Packing Group (it any)) No, Type Quantity WWnI. <br /> K <br /> Z 2. <br /> W ' <br /> 3. <br /> 4. <br /> l4d %rdalliandlarg Instructions andAik"onal information <br /> I . Il♦:. . <br /> P141fif� fila . ! itifyf ld:l I. i 6rccafarti afar lip, 0110pill <br /> 110 P! is F�(2 1029 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION; I hereby declare tha(the contents of this consignment are fully and accurately described above by the propershlpong name, and are classified, packaged, - <br /> markedandlabeleNplacarded, and are in all respects In properoorditon forhansport according to applicable latemallonaland national governmental regulators. Ilexport shipment and l am the Primary : <br /> Exporter, l certify that the contents of this consignment omfomr to the terms of 0e attached EPAAdmoWedgmentof Consent, <br /> I corbfy that the waste minimiraton statement Identified in 40 CFR 262.27(x) (til am a large quantity generator) or (b) (Ill am a small quam0ygenerator) ISM. <br /> Geneator'slOOerofs Pdntedrtyped Name Signature ,. . �.' Momh+ . Day Year -. <br /> : �• �� / � <br /> J 18. International Shipments <br /> F ❑ Import to U.S. LJ Export from U.S. Pad of entry/mill: <br /> Transporter signature (for exports only): Data leadng U.S.: <br /> 17, TanspaderAcknowledgrantof Receipt of Materials <br /> ce Transported Pdntedrryped Name Signature i Monty'illippliIDey Year <br /> a r ! r r ! <br /> f 4 I <br /> Taraporter2 PdnledRyped Name Slgnatic Month Day Year <br /> r— <br /> .} 1e, Discrepancy . . <br /> Ise, Discrepancy Indication Space ❑ Ouantry ❑ Type El Residue ❑ Partial Reledion ❑ Fug Refectan <br /> Man9eslRefererxe Number. <br /> 18b.Alternate Fadrdy (or Generator) U.S. EPA IO Number <br /> J <br /> U <br /> ta+. Facltys Phone: <br /> w 8c Signature ofAllemate Fidlily (or Generator) Month Day Year <br /> Q 9 <br /> Z _ <br /> Hazardous Waste Report Management Method Codes Q.%, codes for hazardous waste heabnen4 disposal, and recydhrg systems) <br /> 1 .. 2 <br /> I �y � <br /> 20. Designated Facility Ovaeror .0pealor. Certification of recopipof hazardous materials covored by the manliest except as noted In Item lee <br /> PdnNNyped Name , ,Signalwe Monty Day Year <br /> PA Form 8700.22 <br /> TRANSPORTER'S COPY <br /> (Rev. 3,05) Previous editions are obsolete. - - " <br />