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Please print or type.(Farm designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No,2050-0039 <br /> 1 UNIFORM HAZARDOUS GDN2 Page 1 3Esp°nse Phone ao. g <br /> WASTE MANIFEST � 2 <br /> 0 <br /> JJ K <br /> 5,Genenato!s Name and Mailing Address Generator's Site Address(it different than nails address) <br /> GeneratOts Pn01@r <br /> 6.Tanstri 1 Com,parry Name J.S.EPA ID Number <br /> 7.Tanspmter 2 Ccmmny Name U.S.EPA ID Number <br /> 8.Designated Facifty Name and Site Address !J S.EPA IO Number <br /> FactIt/s Phone:` <br /> ga. 9L U .DDT Deaaipllan;'mcicdng Groper SClFping Name,Hazard Class,ID Number, 10.Containers 11,Total 12.Urn <br /> HM aro Packing Group if an71i No. Type Quantity N"Not. 13.Waste Codes <br /> 7... .. <br /> K <br /> W <br /> 2 2 <br /> W <br /> 3, <br /> 4. <br /> I <br /> 14.Special Handling Ins ructons and Additional Information <br /> 15. GENERATOR'SIOFFEROR'SCERTIFICATION: hereby declare that the contents of this consignment are fully and accurately deserted above by the proper shipping name.and are classdSd,packaged, <br /> marked and labeledlplanh ed,and are in all mspecas!n proper condition for transport according to appfcable m emefional and national governmental regulations.If export Shipment and I am the Primary <br /> Exporter.I certify that the contents reins consignment conform to the terms of the attached EPAAckrawiedgmenl of Conant <br /> I Poorly that the waste minimization slalement'!den95eo In 40 CFR 262.27(a)(if I am a large quantity geoeraror)or tb)(if I am a smolt quantity generator)is We. <br /> Generator's,01i is Pnn,od:Typed Name Signature Month Day Year <br /> 18.Intemationai Shipments <br /> In- ❑Impart to U.S. ❑Export from U.S. Pon of erery;'exA <br /> 2 T:-an=_poMr Signature(tor experts only). Date Saving U.S: <br /> W170 Therm, erAcmavleagment of Receipt of Materials <br /> Transporter 1 PriledTyped Name Signature Month Day Year <br /> a <br /> N <br /> 4 iransportar2Pdnled.Qyped Name signature Nmnth Day Year <br /> of <br /> t <br /> 18.Dscrepancy, <br /> 18a,Discrepancy Indication Space ❑ Quantity ❑Typ r ❑ResidueEl ec' <br /> Partial R)e' bon Full RaiecBon <br /> Mantissa Reference Number. <br /> 18b.Alternate Facftf(or Generator) US.EPA ID Number <br /> J <br /> U <br /> u Facility's Phone'. <br /> w 18c.Signature ofAtemate Facility(or Generator} Month Day Year <br /> a <br /> z <br /> y19.Hazardous'Naste Report Management Method Cordes(i e..Faces for I'maordous waste treatment,dispose:,and recycling systems) <br /> Ca 1 2. 3. 4. <br /> 20.Designated Facility Omer or Operator Certification of receipt of hazardous materials covered by the mandesl except as noted In Item!Be <br /> 'imediTyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL.COPY <br />