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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.Manifest Tracking Number <br /> WASTE MANIFEST - G�2 9609 JJK <br /> 6Generala's Name and Mailing Address Generators SiteAddress(if different than mailing address) V „ <br /> Generator's Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7,Transporter 2 Company Name U.S.EPA ID Number <br /> 8,Desgnated Facility Name and Site Address U.S.EPA ID Number <br /> Facility's Phone: - - - <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers11.Total 12.Unlit 13,Waste Codes <br /> HM and Packing Group(if any)) <br /> No. Type Ouemiry WINd. <br /> a' J <br /> W <br /> 3.. , <br /> 4.;t <br /> 14.Special Handling Instmctions and Additional Information <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged <br /> marked and labeledlpacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I em die Primary <br /> Exporter,I candy that the contents of tits consignment conform to the terms of the attached EPAAcknow7edgment of Consent, <br /> I caddy that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)fdI am a small quantity generator)is true. <br /> Genenum-slOffi is PrinteciTyped Name Signature Month Day Year <br /> _ r ' <br /> —r 16.International Shiprents <br /> F ❑Import to U.S. ❑Export from U.S. Pon of entrylexit <br /> = Transporter signature(fair exports only): Date leaving U.S.: <br /> W17,Transporter Acknowledgment of Receipt of Materials <br /> t j Transporter t Pdnaillryped Name Signature Month Day Year <br /> g <br /> H <br /> Ta Transporter PnntedTypetl Name Signature Month Day Year <br /> K <br /> t- <br /> 4 18.Discrepancy <br /> 1 B.Discrepancy Indication Space ❑ Owm <br /> 8Y Type Residue Partial Rejection FWI Rejettpn <br /> Manifest Reference Number: <br /> 1 Bb.Allemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> LL Facility's Phone. <br /> IBe.Signature of Alternate Facility(or Generator) Monty Day Year <br /> Q <br /> 2 <br /> Crt 19.Hazardous Waste Repan Management Method Codes(I.e.,codes for hazardous waste treatment,disposal,and recycling systers) <br /> N <br /> W 1. 2. 3. 4. <br /> 20,Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manliest except as noted in Item 18a <br /> PrintedRyped Name Signature Months Day Ym <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL.COPY <br />