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Please prinl'or type.(Form designed for use on elite 442-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number t 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE.MANIFEST A K <br /> 5.Generator's Name and Mailing Address Generators Site Address(irclifferent than mailing address) <br /> Generators <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> r r: <br /> 7.Transporter 2 Company Name U.S.EPA 19 Number <br /> 6.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Facility's Phone: <br /> ga, 9b:U..S.DOT Description(including Proper Shipping.Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quantity WtJVoI; <br /> Z 2. <br /> w <br /> CD <br /> 3. <br /> i <br /> f i <br /> 4. ' {. <br /> t <br /> 1 <br /> 14;3pecial Handling Instructions a nd.Addillonal.lnionnation <br /> ! <br /> moi`�' "� $ a�� �� �•., <br /> 15. GENERATORVDOEROR'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 labeledlplacarded,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 cedly,that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> )certi that the waste minimization statement identified in 40 CFR 262.27 a if lam a large uanti '� " <br /> ty O( rg q ty generator)or(6)(if l am a�lfiall quantit�l genen6tor)is trfie. <br /> GemeratbeslOfferors Pnnted/Typeil Name Signature a� /. i MonthDai Year <br /> —i 16Antemational Shipments - <br /> f, ❑Import to U"S. ❑Export from U.S, Port of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.TransporterAcknowledgment:of Receipt of Materials <br /> Traansporter 1 PrintedFTyped Nafie Si nature <br /> �y ) Month Day year <br /> °- w,.0. 4`"..`t + .. 5,..•'F. {,-,+�`.i�`t 1..,.y &�»..�`+._ „• xx q ' � �'--'i - ^`. ..r�.,... <br /> Z Transporter 2Printed/Typed'Name "Signature Month Day Year <br /> F-- <br /> 18.Discrepancy, <br /> 18a.Discrepancy Indicatlon.Space ❑ Quantity1 ❑Full Rejection <br /> El ❑Residue Partial Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> V <br /> ra Facility's Phone: <br /> w 18c.Signature ofAltemale Facility(or Generator) Month Day Year <br /> d <br /> Z ' <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> Uj <br /> 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item t6a <br /> Pdrited/ryped Name Signature Month Day Year <br /> =PA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY'S COPY <br />