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Please print or ( 9 f v <br /> p type: Form desi ned,or use on elite(12•pifch}typewriter.) <br /> 1.Generator ID Number Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 2.Page 1 of 3.Emergency Response PhoLIM <br /> st Traclking Number <br /> WASTE MANIFEST t�(� y�5.Generator's Name and Mailing Address J J K <br /> Generator's Site Address(if different than mang address) <br /> Generator's Phone; <br /> 6.Transporter 1 Company Name / <br /> U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address <br /> U.S.EPA ID Number <br /> Facility's Phone: <br /> ga, 9b.U.S.DOT Description(Including Proper Shipping Name,Hazard Class,11)Number, 10.Contalners <br /> HM and Packing Group(if any)) 11.Tod 12.Unit 13.Waste Codes <br /> 1. ?, No. Type Qu (lily wtivol. <br /> 'a+ TJ "i. <br /> z 2. <br /> LU <br /> 3 1n1 <br /> CUIU�ii.._ <br /> 4. EM i <br /> MIA�_ <br /> 14.Special Handling Instructions and Additional Information EALT DEPARTMENT <br /> 15. GENERATOR'SIOFFERORIS CERTIFICATION: I hereby declare that the contents of ails signment are fully and accuralely.described above by the proper shipping name,and are classified;packaged, <br /> marked and labeled/placarded,and are in all respects in proper condillon for transport a ding to applicable intemationaland national governmental regulations.If export shipment and I am the Primary <br /> Exporter,l certify that the contents of[his consignment conform to the terms of the aftac d EPA Acknowledgment of Consent' <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a rge quantity generator)or(b):(if ram asmaJl,quantity generator)is trfie <br /> Generators/Offeror'sPrinted/Typed Name SignatureYeer <br /> 16.International Shipmenis �' f <br /> Z ❑Import to U.S. ❑Export from U.S. Port of entrylexd: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> w 17:TransporterAcknowledgmentofR_eceipl.ofMaterials <br /> OTransporter 1 Printed Typed Name' p / Signature Monlfr Day Year <br /> a <br /> Q Transporter 2 Pniiedffyped Name <br /> Signature "Month ` Day Year <br /> F- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> 18b.Alternate Reference Number <br /> Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U. <br /> LL Facility's Phone: <br /> 18c.Signature of Aftemate Facility(or Gene r tor) <br /> Month Day Year <br /> a <br /> Z <br /> W19.Hazardous Waste Report Manage ent Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> O 1 r 2. .3• 4. <br /> 20.Designated Facility Owneryor .Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a. <br /> Printed/Typed Name Signature Month Day near <br /> EPA Form 8700-22(Rev.3 5) Previous editions are obsolete. <br /> nF.ctr_nteTFn corn r•rv,e rnov <br />