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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 11.Generator ID Number 2.Page 17. me,,ency Response Phone Manifest Tracking Number <br /> J J K <br /> WASTE MANIFEST , I I <br /> 5.Generator's Name and Mailing Address Generators Site Address(it different than mailing address) <br /> + <br /> Generators Phone: J- ::1 4.V4- <br /> 6.Transporter I Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> tj <br /> FacJljVs Phone: <br /> 9a, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wtfvol. <br /> F <br /> ......... <br /> 0 <br /> 2. <br /> LLI <br /> 3. <br /> 4. <br /> 14.Special 1-landling Instructions and Additional Information <br /> -1 c11 is <br /> -71 <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,ard,areclassified,packaged, <br /> marked and labetedfol I acarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations)texport shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms o1 the Attached EPA Acknowledgment of Consent <br /> I certify that the waste minimization statement Identified in 40 CFP,262.27(a)(if I am a large quantity generator)or(b)(it I am asmall�quantity generators tdue,/' <br /> Generator'slOfferor's Printed[Typed Name signature Month Day Year <br /> A% <br /> y <br /> —J 116.International Shipments 'E.port from U.S. Port of entry1sxit: <br /> El Import to U.S. <br /> Transporter signature(for exports only,): Date leaving U.S.: <br /> LAW 17.TransporterAcknowledgment of Receipt of Materials <br /> Transporter 1 Printed Typed Name Sigy*rep 2 Month Day Year <br /> 0 <br /> Zco <br /> Transporter 2 PrintedrFyped Name SfgnatUre Month Day YeAr <br /> I18.Discrepancy Full Rejection <br /> 18a.Discrepancy Indication Space El Quantity El Type EIResidue Partial Rejection ❑ <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA 10 Number <br /> LL- Facility's Phone: <br /> 0 <br /> Lu 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1" 1 2. -T 4. <br /> 0 1. <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 Month Day Year <br /> EPA Form 8700-22(Reiv.3-0 ) Previous editions are obsolete.� DESIGNATED FACILITY'S COPY <br />