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.:ieasa print or type.(Form designed for use on elite(12-pitch)typawther.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS :11,Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.ManNest Tracking Number <br /> WASTE MANIFEST IOGY-16954 JJK <br /> 5.Gonenidors Name and Malling Address Generators Site Address(if different than mallIng address) <br /> Generators Phone;,- <br /> 6.Transporter I Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA 10 Number <br /> 8.Designated Facility Name and Site Address U.S.EPA 1D Number <br /> Facility's Phone.a' <br /> go. 9b.U.S.DOTDucdpflon(Including Proper Shipping Name,Hazard Class,ID Number, 10,Containers 11.Total 12.Unit %Waste Codes <br /> HM and Packing Group(If any)) No. Type Quantity WLVd <br /> 0 . fib <br /> 4. Fi <br /> 14,Special Handling Instructions and Additional Information <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of th's%bnsignment are fully and accurately described above by the proper shipping name,and Era classified,packaged, <br /> marked and labeledi'placarded,and are in all respects In proper condition for transport according to applIcable Internatonal and national governmental regulations,If export shipment and I am the Primary <br /> Exportar,.I certify that the contents of this consignment conform to the terms of the attached EPAAckriowledgment of Consent. <br /> I certN-Llal the waste minInn7stion statement Identified In 40 CFR 262.27(a)(it I am a large quantity generator)or(b)Of I am a small quantity generator)Is two. <br /> Generalor'slOffistror's Printacirryped Name Signature J.y,r Month Day Year <br /> Iq <br /> 16,.!ritomaltonal ShlorriarlIs <br /> D Import to U.S. El Export from U.S. Port of entry/exit <br /> -Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment o(Reoelipt of Materials <br /> 0Traqy <br /> qp, N amB SIqnBtura Month Day Year' <br /> 0 . ...... <br /> EL <br /> ZI/) <br /> Transporter 2 PrIntatirryped Name Signature Month 'Day Year <br /> 118.Discrepancy <br /> 18a.Discrepancy Indication Space ❑Quardity ❑Type 0 Residue ❑Partial Rejection El Full Refection <br /> Manifest Reference Number. <br /> 18b,Alternate Facility(orGentirator) U.S.EPA ID Number <br /> L:I- Facility's Phone: <br /> ulC3 Month Day Year <br /> 18c.Signature ofAJIemade I'siellity(or Generator) <br /> 0 <br /> VS 19.Hazardous Waste Report Management Method Codes(i.e.,oDdes for hazardous waste treatment,disposal,find recycling systems) <br /> LIJ 1. 2 <br /> 3. <br /> 1 4. <br /> 20.Designated FadIlly Owneror Operator:Codification ofracelpt of hazardous materials covered by the manifest except as noted In Item 180 <br /> Printed/Typed Namo signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous edIflons are obsolete, GENERATOR'S INITIAL COPY <br />