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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.Page 1 of 3.Emergency Response Phone 4.ManNaat Imming Number <br /> WASTE MANIFEST : + e - JJK.. K <br /> 5.Generator's Name and Meiling Address Generator's Site Adtlress(if dl8erent than melting adU tlreae) <br /> Generator's Phone: <br /> 6.Transporter 1 Company Name U.S.EPAID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Facility's Phone: - <br /> ga, 9b.U.S.DOT Description(Including Proper Shipping Name,Heated Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM I Packing Group(Harty)) No. Type Quantity Wt.Nol. 13.Waste Codes <br /> 1. <br /> C <br /> `O <br /> C <br /> W <br /> W 2. <br /> 3. <br /> 4. <br /> 14.SpKW Handling lrsbuctlone and Addaw Information <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment ars fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplecarded,and are in all respects In proper condition for transport according to applicable international and national govemme itel regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the tams of the aaeched EPAAcknuwledgment of Consent. <br /> I candy that the waste minimization statement Identified in 40 CFR 262.27(e)(d 1 em a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generator's/OSerafs Pdnted/Typed Name Signature Month Day Year <br /> J 16.International Shipments <br /> ❑Import to U.S. ❑Export from U.S. Pod of enhylexit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> 17.TrensporterAcimowledgmentaf Receipt of Materials <br /> Transporter 1 Pdnted?yped Name <br /> Signature Month Day Year <br /> Q. <br /> N <br /> Z Trensporter2 Pdntsdfypeame <br /> rd Name <br /> Signature Month Day Year <br /> t— <br /> } 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> Quantity ❑Typo ❑Rasitlue F1 Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> iBb.Alternate Facility(a Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> 181 Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> 2 <br /> H19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems) <br /> O 1' 2. 3. <br /> 4. <br /> 1 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18e <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />