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Please print or typX <br /> .4 <br /> UNIFORM HAZ,gRDOUS 1 Generator to Number rm FaApproved.OMB No 2050-0039 <br /> W E MAl11FEST l / Pa3e 1 cf 3-Emergency Response Phone 4.Manifest Tracking Number <br /> 0 2 4 2 6119 J J K <br /> Ma4utg Address �f l Generators Site Address than(d different mailing address) <br /> vener31=' <br /> alor'nt 17. 5'�e i�f Ii 1 k <br /> 6.Transporter 1 - /�M - %'. f <br /> George.W .d In US EPA ID Number <br /> 7,Transporter 2 Company Name <br /> U.S.EPA ID Number <br /> 8. 2Maf�1n46111t9111PMUI,_c t <br /> 31918�Mf}7J$�R�q( U.S.EPA IDrii,mt r <br /> PiOPKER SOUTH,AZ 053" <br /> F-iys Phone: 177"227-01e9 <br /> 9a. 9b.U.S.DOT Description(Including Proper Shipping Name,Hazard Class,ID Number. <br /> HM and Padting Group(darty)) 10-Containers11.Total 12.Unit13.Waste Codes <br /> t fdrJNT' F1•?fir r, No. Type Quantity Wt.Nol, <br /> o v SOt1f] ioc; <br /> WIFt <br /> ( �f r <br /> z \\ <br /> W <br /> 4 <br /> 14..S 'at Handling InsWct ons and Additional Information <br /> C1RCN 171 <br /> USE GLOB TS IP7VOli;r.'r <br /> I <br /> 15 GENERATOR'S/OFFEROR'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 condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that 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)(ill am a small quantity generator)is true. <br /> Generator's/Offerors Printed/Typed Name Signature <br /> Month lDay Year <br /> 16.International Shipments <br /> Z ❑Import to U.S. ❑Export from U.S. Port of entrylexit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> 0 17.TransporterAcknowledgment of Receipt of Materials <br /> LLJ <br /> Transporter 1 Printeciff d Name Signature <br /> O1 �' Month Day Year <br /> Transporter 2 Printed/Typed Name !L <br /> Signature Month Day Year <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection <br /> ❑Full Rejection <br /> Manifest Reference <br /> 18b.Alternate Facility(or Generator) Number: U.S.EPA ID Number <br /> J <br /> U <br /> Facility's Phone: <br /> W18c.Signature ofAlternate Facility(or Generator) <br /> Q Month Day Year <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> D 1. 2. <br /> T3. 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 Signature <br /> Alonth Day Ye, <br /> EPA Form 8700-22(Rev, 12-17) Previous editions are obsolete. <br /> GENERATOR'S INITIAL Ct <br />