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Pleea$prigt.oi type.(Form designed for use on elite(12-pdM) iter) Forth Approved.OMB No.2050-Mg <br /> UNIFORM HAZA('iDOI(S 1:Gererear N Number 2.Page i of 3.Emergency Response Phone 4.11 TnrJdna Number <br /> WASTE MANIFEST -•r., ,,. , ti 1�w7 ! , moi ?` "5.. JJK <br /> S.Generalor's Name and Mailing Address Genemors Site Address in different than mall g address) <br /> Garenoes Phi: ., . <br /> 6,Transporter I Conp"Nams U.S.EPAID Numbw <br /> 7.Twmpoder2moveny Name U.S.EPA ID Nu r <br /> r <br /> 8.Designated Facifty Name and Site Address U.S.EPAID Numaer\ <br /> Fadi 'e Phone: <br /> ge. tib.U.S.DOT Description(Including PmperShipping Name,Hazard Claw,ID Number, 10.Containers 11.Total 12 UM , r <br /> HM and Pw*.hg Group(gang)) No. Type OuanMy, yAm 13.Waste Codes <br /> 1.r ..,a r1 ry• •. '.s 't. ..lr ..:. _rg:.'r..: Pp <br /> X <br /> LD <br /> 3 <br /> 4. <br /> 14,Special Handling Instructions and Additional Irdormanion <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare had the contents ofthis consignment are roily and accurately dwaibed soon by the proper shipping name,and are devilled,packaged, <br /> marked and Iabeledlplawrded and are in al respects in proper condition for transport according to applicable inlemadonaland national gownwre dal regulations.If export shipment and am the Primary <br /> Exposer,I ceNly that the contents of NIs consignment conform to he tames of the agacmed EPAAdaowledgment of Consent. <br /> I cattily,that the waste minimization statement idemiled in 40 CFR 26227(x)(l I am a large quantity generator)or W am ajpl quantity generator)is nu <br /> Genes emfs Pdnledrfyped Name <br /> signs hro f!j Dry_ Year <br /> 16,Inamational Shipments rr <br /> ❑Import a U.S. ❑Exporttrem U.S. Port olenmyledl: <br /> Transporter signature(for exports only): Das lowring U.S.: <br /> 17.TwspanerAclaowadgment of Recelpt of Materials <br /> 12 W. Transports,1 PmndlTypetl NerOe...,_ Slgneture _ AAM Day Yar <br /> nnepaar2Fpgt1tdr7yped Name Swuriure Month Day Year <br /> j18.Dlsorapancy .• - ' <br /> 10e.Diampancy Ndlcalbf'Spece ❑ Ouardty ❑Type ❑Residue ❑Pad'el RalecVon ❑Ful R*d, <br /> Manifest Reference Number: <br /> l lix Alternate Facility(a(mneraar) U.S.EPA ID Number <br /> J <br /> U <br /> tai Facility's Phone: <br /> ten.Signature ofARemateFadlly(or Generator) Month Day Year <br /> a <br /> z <br /> US te.Haaareow Wade Report Management Method Codes(I.e.,codes for hazardous wase Insentient.disposal,and recycling systems) <br /> G 1. 2. 3. a. <br /> 4 <br /> l <br /> 20.Designated Fecllly Owneror Operator:Canhfxatl of receryt of hanordow materials covered by the manliest except as ncteo fn brq 1 B <br /> Printed/Typed*m, MOW ,y Ye)w <br /> EPAForm 8700-22(Rev.3-05) Previous editions am obsolete. .�' TRANSPORTER'S COPY <br /> 1 <br />