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Please Ont or type.(Form designed.for use on elite(12-pitch)typewrfter.) -Formi Approved.OMB No.2050-0039 <br /> 1.Generator ID Number of 3.Emergency Response Phone 14.Mama Ir" Nuffdw <br /> UNIFORM HAZARDOUS <br /> WASTE MANIFEST I j -,,, ,,-. ,.i . -11 - - 1 005E12319 JJK <br /> General es SiteAddress(1different than mailing address)Generators Name and Mailho Address <br /> Generators Phone: U.S.EPA ID Number <br /> 6.Transporter I Company Name <br /> hTu IL2 vtc <br /> 7,Transporter 2 Company Name U.S.EPA ID Number <br /> 8:Designated Facility Name and Site Address <br /> (7) U.S.EPA ID Number <br /> Faclfil es Phone: -:.3 N1' .I <br /> 9a 9b.U.S.DOT D--"-Crdudlng Proper Shipping Name,Hazard Class,ID Number, 10.Coon 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(If any)) No. Type Quantity vvt,ml_ <br /> 'Ne <br /> 0 <br /> LLI <br /> Z 11 <br /> LIA <br /> S <br /> 3 <br /> I L <br /> 14.Special Handling InstruclJons and Additional Infonati <br /> 15 GENERATOR'SIDFFEROR'SCERTiFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are dassiW,Packaged, <br /> marked and labelediplacaTded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,V certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent- <br /> I certify that the waste minimization statement identtfied in 40 CFR 262.27(a)(I I am a large quantify generator)or(b)(K I am a small quantity generator)is true. <br /> Guneratof'slOffines Printe&Typeo Name signatule-- IMonth Day Year <br /> j a Ly <br /> F j 16.International Shipments El Import to U.S. ❑Eprt from U.S. Port of entryle& <br /> Transporter signature(for exports only): Date€eaying U.S.: <br /> % 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printedffyped Name Signature r Month Day Year <br /> U) <br /> 92- <br /> 2t Transporter 2 PrintedrTyped Name Signature Month Day YOW <br /> 18.Disciapancy <br /> 16a.Discrepancy Indication Space E-] Quantity Ty e Residue El Partial Re#ecfion Q F.11 Rejection <br /> Manifest Number <br /> - <br /> 18b.8b.Alternate Facility(or Generator) RECE U.S EPA ID Number <br /> U JUN 2 2 2015 <br /> Facility's Phone: Month Day Year <br /> QLU 18c Signature ofAlternateFadhy(or Generator) <br /> ENVIRONMENTAL <br /> 0 19,Hazardous Waste Report Management Method Codes(!�e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> UA 1 2. 3. 4 <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in item 18a <br /> PrlrtewFyp d—Name Signature Month t Day I Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. TIIANSPORTER'S COPY <br />