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Please print or type.(Form designed for use on elite(12-pitch)fear.) • Form Approved OMB No.2050-0039 <br /> 1.Generator ID Number 2.P g 1 of 3.Emer en Response Phone 4.Manifest TrackingQpo �( <br /> UNIFORM <br /> WASTEM HAZARDOUS 0 (_.;(:.0 . . ) �'"' ` ...-1 1 �! ' i 9: .. P . t1 5304489 JJK <br /> S.Generators Name and Mailing Address Genergtyr�deAddress it different than mailing address) <br /> LC J <br /> Generators Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Fadlity's Phone: - <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quantity vii <br /> tY 1. :. <br /> 0 it <br /> 2 2. <br /> W <br /> CD <br /> 3. <br /> 4. <br /> I.Special Handling Instructions and Additional Information <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment am fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplamirded,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 teems of the attached EPAAcknoMedgment 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 /> Generators(ORemrs PrintedfTyped Name Signature' "/ Month Day Year <br /> rJ 16.International Shipments <br /> Z ❑Import to U.S. ❑Export from U.S. Pon of enhylexb: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name, Signature Month Day Year <br /> a >. <br /> rn ` <br /> Q Transporter 2 Pdntedffyped Name Signature's Month Day Year <br /> K <br /> h <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type El Residue R E I e 'on ❑Full Rejection <br /> Manifest Reference he <br /> 1 Sb.Alternate Facility(or Generator) .L E umber <br /> J <br /> LL Fa6lity'sPhone: E"v17YF�QNd!P'N1AI. F1F?,IT}{ <br /> cmn-. <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> c^ <br /> r Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> L2. 3. 4. <br /> O <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Pdnted(Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev,3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />