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Please pant or type.(Form designed for use on elite(12-pitchl 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 n-i JJ K <br /> U.L 4: '. <br /> 5.Generates Name and Mailing Address Generators Site Address tit different than mailing address) <br /> Generator's Phone: - - <br /> 6.Transporter 1 Company Name 115.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Faalily's Phone: — 'r <br /> 9a go.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number10.Containers 11.Total 12.Unit <br /> , <br /> HM and Packing Group(9 any)) No. Type Quantity VJLNol. 13.Waste Codes <br /> 1. <br /> cr <br /> O <br /> 4a <br /> w <br /> z 2. <br /> w <br /> f0 <br /> 3. <br /> 4. <br /> :14.,Special Handling Instructions and Additional Information <br /> 15. GEN ERATOR'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 Iabeledlplacarded,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 /> Generatofs(Offerors P-rintedlryped Na me Signature ,- _._..- __.. Month Day Year <br /> 16.International Shipments <br /> s— ❑Import to U.S. ❑Export from U.S. Port of entry/exit <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> OTransporter 1 PrintedlTyped Name _ Signature Month Day Year <br /> a <br /> n <br /> Q Transporter Pnnted/Typed Name Signature Month Day Year <br /> C <br /> H <br /> } 18.Discrepancy <br /> 16a.Discrepancy Indication Space rRejection ❑Full Rejection <br /> El Quantity ❑Ty epiUtYE Partial <br /> 'es <br /> I Reference Number. <br /> F 18b,Ntemate Facility(or Generator) [ U.S.EPA ID Number <br /> J <br /> U <br /> LL Faciliys Phone: EEM\itRIONMEk7AL I UXTH <br /> w fee.Signature of Alternate Facility(or Generator) PM Z1911 I ME R-J .a Month Day Year <br /> z <br /> z <br /> CD_ 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> _. 2. 3. 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 /> Printedrfyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />