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01/29/2013 16:52 FAX 12094658060 B17L.KST0CKT0N@BULK—DTI.00 Z0007/0008 <br /> Please print:or type.(Form designed for use on elite(12-pitch)typew*j- . Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Ge erator ID Number 2.Page 1 of 3.Emergency Response Phone 4,Manifest Tracking Number <br /> S WASTE MANIFEST .�. ., + `Nr x1.. '008643852 JJK <br /> 5.Generator's Name and MailiAddress Generators Site Add-ass(if different than mailing address) <br /> Generators I t6ii: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> l' L'vwiZ ii 4,i V <br /> a 7.Transporter 2 Company Name <br /> U.S.EPA ID Number <br /> 8.Designated Facility Name and SiteAddress U.S.EPA ID Number <br /> Facility's Phone: 4114,.,, <br /> ` ga 9b.U.S.DOT Description(including Proper Stopping Name,Hazard Cfass,ID Number, 10.Containers 11•Total 12.Unit <br /> 3.Waste Codes'.'• <br /> HM andel Packing Group(if any))) No. Type Quantity Wtivol. <br /> � 1.r?+"�dF`/�`r��`� 'r'I,+.n"�*f,'±�°:1F°i+..'�'-�"Yc�''"_�o d#-._'Jr�l.�%i dam• r.��"';��� �/'�}•,/��.,. pp <br /> Z 2. <br /> W <br /> t.7 <br /> 3. <br /> G 4. <br /> 11 <br /> 14,Special Handling Instructions and Additional Information <br /> t <br /> ar,;.� r-�1••ra,r" .'�°` <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 appiicab,e intemational and national governmental regulations.if export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform lo the terms of the attached EPA Acknowledgment of Consent, <br /> x. I certify that the waste minimization statement identified in 40 GFR 262.27(x)(V I am a large quantity generator)or(b)(AI am a small quantity generator)is true. <br /> Generata'slOffemrs Pronted/fyped Name Signature yr Month Day Year <br /> J.e, ,iF'' S' <br /> 1 .International Shipments <br /> � ❑Import to U.S. ❑Export from U.S. Port of entrylaxll: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> 17,TraruporterAcknowiedgment of Receipt of Materials <br /> Transporter 1 PrintedlTyped Name Signature .. . _. t Month Day Year <br /> x <br /> N <br /> Q Tra rter 2 Pr ntedlfyped Name Signature Month Day Year <br /> 1 B.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Re)ection <br /> 7 <br /> Manifest Reference Number. <br /> f 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> LL FaroTitys Phone: <br /> i&.Signature of Alternate Facility(or Generator) Month Day Year" <br /> ' a <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> Ul 1. 2. 3. 4. <br /> 1� <br /> 20.Designated Facility Owner or Operates;CertffiCatbn of receipt of hazardous materials covered by the manifest except as noted in Item 18a .� <br /> PrintedrTyped Name Signature < Month Day Year <br /> I <br /> t: <br /> EPA Form 870D-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />