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Plea se'pnint or type.(Form designed for use on elite(12-pitch)typewriter.p 2. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Pmg lof 3.Emergency Response Phone 4.Manifest Trackin umber <br /> WASTE MANIFEST J J F L E <br /> 5.Generators Name and Mailing Address Generators SileAddress(if different than mailing address) <br /> (.41-Wfm r'61 5 0 <br /> Generators K6ne: 4,t-f.yittf,oi <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 4*an I li.trbm s Fnvironnwwai ci`i&i-viv-i# mc. of '.I P tj f- ei <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA 10 Number <br /> (Pat,Irl 3f'o*r 5 L.-c%?.tjisj%v 111 uik,i <br /> A 0!9 f9 0 <br /> 9a. 9b,U.S.DOT Descriplkin(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11 Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity WI.Nol. 13.Waste Codes <br /> 1. <br /> 2. <br /> to <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 15. GENERATOR'SIOFFEROR'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 cond,tion for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify[hat the contents of this consignment conform to the terms of the attached EPA Acknowledgment 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)(K I am a small quantity generator)is true. <br /> Generators101ferors Prinledryped Name z5lgnatum; Month Day ear <br /> —J 16.International Shipments <br /> 1:1 Import 10 U.S, E]Export from U.S. Port of entrylexil: <br /> Transporter signalure for exports only): Date leaving U.S.: <br /> LW 17.TransporterAcknowledgment of Receipt of Materials <br /> a Transporter 1 Printed[Typled Name rte onth Day —7ear <br /> 0 <br /> Transporter 2 Printeffyped Nam f onth Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space 0 Quantity ETYP. ❑Residue Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> LL Facility's Phone: <br /> LIJ 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Z <br /> 0 <br /> r, 19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems) <br /> LLI 1. 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 /> Printed/Typed Name pp Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br /> it Or,on 61,q 0 emit�im aild w ill w opt Of f-65�,-irre oeiiatcr i5 41,ijapfflit, <br />