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Form roved.OMB No.2050.0039 <br /> Please print or type.(Form designed for use on elite(12-pndir?yprvrter.) APP <br /> } UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> i qq JJK <br /> WASTE MANIFEST j t., <br /> 5.Genera7t 's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> Generatols Phone: <br /> 6.Transporter 1 Company Name U.S.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 /> Facility's Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hand Class,ID Number, 10.Containers 11.Total 12.Unit <br /> 13.Waste Codes <br /> HM and Padang Group(hany)) No. Type Quantity wt./Vol. <br /> 1 <br /> of <br /> O <br /> ofof <br /> w <br /> w <br /> z 2 <br /> w <br /> f7 <br /> 3 <br /> 4 <br /> '^ Special Handling Instructions and Additional information <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 EPA Acknowledgment 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 /> GenemtolstOfferols Pnntedlfyped Name Signature - Month Day Year <br /> zi16.International Shipments <br /> iElImport to US. ❑Expwt from us. Port of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter AcknoMedgment of Receipt of Materials <br /> Transporters PrintedlTyped Name Signature Month Day Year <br /> O <br /> a <br /> y <br /> Q Transporter Printed/typed Name Signature Month Day Year <br /> F <br /> i <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ElQuan <br /> Quantity Type Residue Partial Rejection Full Rejection <br /> Manifest Reference Number: <br /> 18b.Mtemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facilhys Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> w <br /> 1m.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> w 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in hem f as <br /> Printed/rypetl Name Signature Month Day "ar <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />