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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 1.Generator ID Number 2.Page 1 0l 3.Emergency Response Phone 4.Mapff�t T eking Nu e <br /> t { ' � <br /> WASTE MANIFEST .i at JJ K. <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> Generator's Phone:T',.;-4,;...•'i: i U.S.EPA ID Number <br /> 6.TranspoFler 1 Company Name <br /> 7.Transporter 2 Company Name U:$.EPA ID Number, <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Facility's Phone' <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12:UNt 13,Waste Codes <br /> HM and Packing Group(If any)) No. Type Quantity WUYol. <br /> 11 A <br /> ( <br /> QQ I I <br /> Z 2. <br /> 0 <br /> 3. <br /> i <br /> 4. <br /> r <br /> 14.Special HandlingIns ruclions and Additional Information <br /> Of <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 /> markeo and labeled)plpcarded,and are In all respects In proper condition for transport according to applicable international and national governmental regulallons.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 /> Icer ify that the waste minimization statement identified In 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(it I am a small quantity generator)is true. <br /> GeneratoeslOBeroes Sin PrintedlTyped Name a Month Day Year <br /> Da , <br /> _r 16,Intematiohal Shipments El Import to U,S. ❑Export from U.S. Port of entry/exit: <br /> .Transporter signature(for exports only): pate leaving,U.S.: <br /> W-1 <br /> 17.Transporter Acknowledgment of Recelpt of Materials : J <br /> Transporter1Prinfed[TypedName ' Signature �! MOON,, Da�tr <br /> Z Transporter 2 Printed/Typed Name Signature Month Day Year <br /> H-t <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number, <br /> 181b.Alternate Facility(or enerator) U.S.EPA ID Number <br /> v <br /> rar- Faplity's,Phone: Month Day Year <br /> L— 18c.Signature of Alternate Faid ity(or Generator) <br /> Q <br /> Z <br /> 0 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> Q 1 2. 3. 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 /> Signature Month Day Year <br /> PrintedtTyped ame <br /> EPA Form 8700-22(Rev,"3.05) Previous editions are obsolete. DESIGNATED FACILITY'S COPY <br />