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•"": iar'1 • form Approved OM5 No.2050.0039 <br /> s .m N Npmbar 2 Page 1 of 3 Emergency Response Phone 4. Tracking Number <br /> -.,..,mr✓ANIFESi1^$• r -� �, y ,;' JJK <br /> 5 Generatprs Name and Mailing Fddress _ Generator's Site Address IT amerent than maIll address) <br /> Generators Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA 10 Number <br /> 8.Designated Facdily Name and Sge Address U.S.EPA ID Number <br /> Fal I's Phone: <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,HazsN Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM andPacking Group(ifany); Na. Type Quantity Wi 13.Waste Caries <br /> K <br /> O <br /> Z 2. <br /> W <br /> cJ <br /> J. <br /> e <br /> 14.Special Hen...9 IIrn-cu ,atm Additional muslu ntn <br /> 15. GENERATOR'SIOFFEROR-SCERTIFICATION: I hereby declare mat the contents of this consignment are fully and accurately described above by the proper shipping name,andare classified,packaged, <br /> marked and labaad,'placarded,and are in all respects in proper condition for transport according to applicable international and national gmmmomal regulations.If export shipment and 1 am the Primary <br /> Exporter,I catty mat the mntards of this consignment conform to the terms of the attached EPAAcknowledgment of Consent <br /> I certify that the waste minimization statement identified in 40 CFR 26227(a)fd I am a large quandy generator)or(b)(il am a small quantity generator)Is true. <br /> Generators/Offercrs PrintedRyped Name SignaNre Monro Day Year <br /> J 76.Internal$h'rpmehill <br /> F ❑Import to U.S. ❑Export from U.S.' <br /> S Pon of entry/exiC <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.TranspoMrAcknowledgment of Receipt of Materiels _ <br /> is, Transporter 1 Printed?ypW Name.. _ SgnaNre ^ / Month Yaar <br /> a � <br /> QTransporter Printetlyfyped Name Signature_ i r/' f Monti Day Year <br /> _ 17" I _. <br /> 18.Discrepancy l_ —. ...__ <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑ <br /> TYPa ❑Residue ❑Penial Rejenron ❑Full Rejection <br /> y <br /> Manifest <br /> t6b.Pllemate Fadlityfar Generator) Reference Number. U.S.EPA IO Number <br /> J <br /> U <br /> u Facility's Phone: <br /> OW 18c.Signature atAlumate Facility(a Generator) <br /> Q Month Day Year <br /> 2 <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposed,and retyping systems) <br /> o t 2, 3. <br /> 4. <br /> 1 20 Designated Facility DA mar or Ope a es Ce tifiafion of hill of hazardous materials covered by me manifest except cop two Ila 18a / —) <br /> dnted?yped Narre <br /> igfmture !': f � I MonthPa <br /> Yearn <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> .-�,u "CtF53GNATEO FAC6LITYTO GENERATOR? <br />