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-0039 <br /> Please print or type.(Form designed for use on elite(12-pitch)' writer.) Form Approved.OMB No.2050 <br /> OUS Generator 11)Number 2,Page 1 of 3.Emergency Response Phone ifest Tracking Number <br /> UNIFORM HAZARD f F 1689GBF <br /> 0000611 <br /> WASTE MANIFEST <br /> 5.Generators Name and Mailing Address Ganerai:6Site Address(W I different than mailing'.address) <br /> J <br /> —11S <br /> Generators Phone: 7 4,(( <br /> .5.EPA 0 Number <br /> 6.Transporter i Company Name <br /> 7 <br /> U.S,EPA ID Number <br /> 7.Transporter 2 Company Name <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Facility's Phone: <br /> 9a. gb-U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers it.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group{if any)) No. Type Quantity Wtivol, <br /> LU <br /> Z 2. <br /> LU <br /> (D - <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional information <br /> IM N Wkc-1 A <br /> I••:,+. -, ',2- UIL <br /> 15. GENERATOR'WOFFEROR'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 govemmental 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 EPAAcknovAedgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(K I am a large quantity generator)or(b)(if I am_a small quantfty-genefator)is true. <br /> Generatoeslofferor's,ftnted/Typed Name Signature Month Day Year <br /> -7 <br /> —1 16.International Shipments ❑ <br /> Import to U.S. El Eqo:'frorri U.S. Port of entrylexit: <br /> Transporter signature{for exports only}: Date leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> Lli <br /> d <br /> Transporter I Printe TrypeiJ.Name Signature Month Day Year <br /> Z Transpohr2 Printed[Typed Name Signature Month Day -Year <br /> rx <br /> 18,Discrepancy <br /> 18a.Discrepancy Indication ❑ El Full Rejection <br /> on Space Quantity El Type El Residue ❑PanJ.I RejL6,, <br /> I Manifest Reference Number: <br /> : 1 Bb.Alternate Facility(or Generator) U.S.EPA ID Number <br /> :3 <br /> 0 <br /> 1 Facilitys Phone: nth Day Year <br /> 18c.Signature of Affernate Facility(or Generator) <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> UJ 1. 2, 3. 4, <br /> !11 -16 r <br /> 20.Designated Facility Owner of Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrintedTFad Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> GENERATOR'S INITIAL COPY <br />