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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1,Generator ID Number 2.Palet of 3.Emergency Response Phone d Manifest Track(no Number <br /> WASrE MANIFEST �,,,€ �„ _._ JJK <br /> S.Gener:tars Name and Mailing Address Generators Site Address(d different then mating address) <br /> Generators Phone: <br /> 6 Transporter 1 Company Name U.S.EPA ID Number <br /> 7,Transporter 2 Company Name U.S.EPA ID Number <br /> 6.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Fadliys Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Container 11.Total 12.Unci <br /> and Packing Grow clan 13.Waste Codes <br /> HM 9 P 1 Y)) No. Type Ouandty WM. <br /> 1. <br /> K <br /> of <br /> ti <br /> z 2. <br /> W <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Addi ional Information <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the pmper shipping name,and are classified,packaged;. <br /> marked and Iabeledlplararded,and are in all respects in proper condition for transport acoord-ng to applicable international and nadonal governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of Me attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimeation statement identified in 40 CFR 262.27(x)[th I am a large quantity generator)or(b)(if1 am a small quantity generator)is true. <br /> GeneratoestORerors PrinteNlyped Name Signature Month Day Year <br /> ...r 16.International Shipments <br /> ❑Impatto U.S. ❑Export from U.S. PM of entry/exit: <br /> = Transporter signature(for exports only): Date leaving U.S.: <br /> a' 17.Transpobe,Aclmowledgmem.of Receipt of Materials <br /> Transporter 1 Printecirfyped Name Signature Month Day Year <br /> O <br /> ZW <br /> Transporter 2 Printed/Typed Name Signature Month Day Year <br /> K <br /> r <br /> I18.Discrepancy <br /> 18x.Discrepancy Indication Space <br /> ❑ Quantity El ❑Residue ❑Partial Rejection Dull Rejection <br /> Manifest Reference Number. <br /> 18b.Alfemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> LL Facilityrs Phone: <br /> W 16c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> N19,Hazardous Waste Report Management Method Codes(ie,,codes for hazardous waste treatment,disposal,and recycling systems) <br /> p 1 2. 3. 4 <br /> 20,Designated Facility Omer W Operator,Certification of receipt of hazardous materials covered by the manifest except as noted in Item Ise <br /> Ante yped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOF 3 INITIAL COPY <br />