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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) t Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3 Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST . . :v[;S)} _ .'a;,- ' r ;,°, i;+ JJK <br /> 5.Generators Name and Mating Address Generelprs Site Address(if different than nestling address) <br /> Generators Phone: <br /> B.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name antl Site Address U.S.EPA ID Number <br /> Facilitys Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hamm Gass,1O Number. 10.Container: 11.Total 12.Unit <br /> and Packing Group(Han i) 13.Waste-Codes <br /> HM 9 Y No. Type Quantity WINol. <br /> _. <br /> 0 f ; <br /> W <br /> t7 <br /> 3. <br /> e <br /> 14.Special Handling instructions and Additional Information <br /> _S '', ': 010[4 - YP?F F'RiRSLE.R.'i��;AiPxRITE !fY, <br /> ,15. GENERATOR'SIOFFEROR'SCSMFICAnON: I hereby declare that the contents of this consignment are kitty and accuretety described above by the proper shipping name,and are classified.packaged. <br /> marked and Iabeledlplaarded,and are in all respects in proper condition for transport according to applicable intemationaland national govemmental regulations.If export shipment and I am the Primary <br /> Exporter.I certify that the contents of this consignment conform to has terms of the attached EPAAcknawledgmenl of Consent. <br /> I certify,that the waste miMmimtion statement identified in 40 CFR 262.27(a)(H I am a large quantity generator)or(b)If I am a small quantity generator(is true. <br /> Generd0(srOlferors PrintedrTyped Name Signature i Monro Day Year <br /> 16.International Shipments ❑Import to LLS ❑Export from U.S. Pon of enbylexit: <br /> Transporter signature(for experts only): Date leaving U.S.: <br /> w 17.TransporterAc"ledgment of Receipt of Materials f <br /> TrenspoTer 1 Pryrle yped Name ! Signature /"., \ Monro Day Year <br /> 2 To nspoater7 Primed ffyped Name `-= Signature Montl1 Day <br /> `-YeaY <br /> Q <br /> K <br /> t- <br /> 4. 1e.0scrapancy v <br /> 18s.Discrepancy Indication Space <br /> ❑ Quantity ❑Type 0 Residue ❑Partial Rejector Full Rejector <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> u FaciMys Phone: <br /> W 18c.Signature of Alternate Facility(or Generelor) Month Day year <br /> Q <br /> Z <br /> d—i 19.Hazardous Waste Report Management Method Codes(.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator.Certfiadon of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name r, Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOP <br />