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Pleasejodr:or ty{}..(Fara designed for use on elite(12-plch)typewriter.) Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1.Gen,suor ID Number 2.Pagel of 3.Emetgenry Response Ptrono 0.M(/anllesl nickRgNum21 {�/ <br /> WASTE MANIFEST U_�..4783119 JJ K <br /> 5 Genervi Now and MaMVAddress Generatofs Sae Address(ddiferentelan maling address) <br /> Generator's Phone. -- "' <br /> 6 Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Trampomr 2 Company Name U S EPA ID Number <br /> e.Designated FadMy Name and Site Address Nu U.S.EPA ID Number <br /> ENVIRONMENTAL <br /> Fasitys Phone r ;. rOADTAKA1T <br /> ga 9b.U.S DOTOescdpson(including Proper SNppmg Name,Harrod Class,ID Number, 10.Connemara 11,Total 12 Met 13 Waste Codes <br /> HM and Packing Group(it any)) No. Type Quantity W1Nal. <br /> 1 � 1 <br /> O _ <br /> K <br /> 2 <br /> 3 <br /> a. <br /> 14 Special Handling Instructions andAddtional lnloonation <br /> 15. GENERATOWS(OFFEROR'S CERTIFICATION:I herebydedam that the contents of We wasignmenl are fully and accurately described above by the proper shipping llame,arcl are classified,packaged, <br /> narked and labeladfplacarded,and ore in as respects in proper comlhon for transport according to applicable ince nationalaM mtmnalgowerranenlal regulatwns.Ileapos alapmem ami I em the Pmmry <br /> Exporter.I car*that the contents of ees consignment conform to the terms of the attached EPAA01,owledgmenl of Consent. <br /> 1 cosily that theaasle minimization statement identified in 40 CFR 262.27(3)(if I am a targe puantitygercero!or)orlb)Cf I am a small guamly genardbQ Is tnce <br /> GenMaWtNDaerofs Pdntedinyped Norrle Si�MNre th Day Year <br /> 1 Irk. i� <br /> J 15,International SNpmems <br /> h ❑kepmttous. ❑Exp ocea U.S. Padolentylexib. <br /> Z Transposer agnature(for exports only) Dale leasing U.S.: <br /> 17.TrdnspoderAftWedgm tofRdce O(Matedals - <br /> Transporter 1 PsnledRY Name ( Sgmt <br /> 4 Transposer 2 Pdnledrfyped Name / Sgmture .� Momh Day Year <br /> .k 1S.EX panty F� <br /> ISO.Discrepancy Indicator,Space El puanuty []Type lJ Repave ❑Penial Rejecwn ❑Fug R*cb.O <br /> Man fest Reference Number: <br /> Wis.Altermle Facility(or Generator) U.S.EPAIO Number <br /> J <br /> U <br /> sai Faculyrs Phone: <br /> w too S'gwwradAl;emale Feciliry(or Genma:cG Morro Day Yea <br /> 6 <br /> Z <br /> a—i 19.Hezallous Waste Repa�Mam9emen1 Method Codee(.e.,oodesfor naaaMeus waeleaaeVnen(.dlepuaal,and recycling sys!ems) <br /> 0 1. 2. 3 d <br /> 20.Designated Famlry Dvmer o dfuraW Cessrlcalbn of receipt of hazardous matelids covered by the manilestexcept as wed in Item 18a <br /> Prinlecirryped Name Signature Moral Day Year <br /> EPA Form 8700-22(Rev.3.05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />