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Please print or type. (Form desioned for use on elite (12-oitchr �.uewriter.) <br />Fnrm Annrn-ri r)MR Ain onrn_nnQO <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />WASTE MANIFEST <br />0 �...1 '.. C1 a 4 JJ K <br />5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />Generator's Phone: }_C -f1 2-1, < tAN+t '. <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />Attt t r g77 [[ yy JJ <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility NameandSite U.S. EPA ID Number <br />pAddress <br />Facility's Phone: 1E "1:. 7 t r":p` (;' A (`t d 4 :{ <br />ga <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10, Containers <br />11. Total <br />12. Unit <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />13. Waste Codes <br />No. <br />Type <br />1. <br />I`,WGR.A RAZA 0(J;WASTE,4..It;t(.41)4011- Wd <br />W <br />A y Y <br />Z <br />2. <br />LU <br />C9 <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information <br />fp4(. '4131iBgr St;O ILL ;0 ',)8 1 'SnRP Y'kI C i f v R <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 labeled/placarded, 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, I 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 identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />Generator's/Offeror's Printedfryped Name Signature Month Day Year <br />P <br />=J <br />16.x ternational Shipments <br />❑ Import U.S. ❑ Port <br />Z <br />- <br />to Export from U.S. of entry/exit: <br />Transporter signature (for exports only): Date leaving U.S.: <br />UJ <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Printed/Typed Name Signature ;- Month Day Year <br />1,. <br />f . <br />QTransport&2 <br />Printedrryped Name" Signature Month Day Year <br />H <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />U <br />Facility's Phone: <br />C3 <br />18c. Signature ofAltemate Facility (or Generator) <br />Month Day Year <br />Q <br />Z <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />" L <br />1. <br />2. <br />3. <br />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 />Printed/Typed Name Signature Month Day Year <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />