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Please print or type.(Form designed for use on elite(12-,pitch)typewriter) Form Approved.OMB No.2650.0039 <br /> ., <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Mpifest Tracking Nlke� <br /> WASTE MANIFEST ; 4'j JJK <br /> t.G—en,,,t,e,,-Nardeabd Mailing Address Generators Site Address(K different than malling address) <br /> Generators Phown i U.S.EPA ID Number <br /> 6.'Transpoder 1 Company Name <br /> 7.Transporter 2 Company Name U:$.EPA ID Number. <br /> 8.DesignatedFacility Name and Site Address U.S.EPA ID Number <br /> Facility's Phone:l�-�)�-'ga - <br /> 9b.U.S.DOT Desaipflon(including Proper Shipping Name,Hazard Glass,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HIM and Packing Group(if any)) No. Type Quantity WtJV01: <br /> F- <br /> 2. <br /> LLJ <br /> 3. <br /> 4. <br /> 14.Special Handling Instructla nSrand Additional Information <br /> -111 . 1, 19D - <br /> w�S110LER1,70 03F I P-'AWE U P <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/plilicarded,and are In all respects In proper condition for transport according to applicable International and national governmental regulations.Ifexport.shlomentand 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'cerfify that the Waste MininniZ811Dn statement identified In 40 CFR 26227(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Month Day Year <br /> Generator`s/Ol1er6esJPhntqfTypad NameSignature <br /> + <br /> -J 16.Infemational Shipments Pod of antrylexit: <br /> Import to El Export from U.S <br /> Transporter signature(for exports only): Date leaving.U.S.: <br /> 01! 17.Tr6nsoortirAdk6owfedgmghioi'RecelptafMaterials uJ Signature. zo�'V Mo hr D'� <br /> F— Yrtnispcider 1 Printacirryped Name <br /> ear0 <br /> CL <br /> . I Month Day Year <br /> V) <br /> Tnihsporter 2 Pddtedffyped—Name Signature <br /> ,jli.Qlscrepjancy <br /> jBa.Discrepancy Indication Space ❑ Quantity El Type EIResidue ❑Partial Rejection El Full Rejection <br /> Manifest Reference Number, <br /> 18b,Alternate Facility(or enerator) U.S.EPA ID Number <br /> FaPilltys Phone: <br /> WMonth Day Year <br /> 18c.Signature ofAJtemate Facility(orGerierator) <br /> U <br /> C!) <br /> 19.HazardousWaste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 7 4. <br /> f 3. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printecirryped 1$ame Signature µ Month Day Year <br /> DESIGNATED FACILITY'S COPY <br /> EPA Form 8700-22(Rev)3.05) Previous editions are obsolete. <br />