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04/09/2012 04:03 #6212 P.003/016 <br /> r, <br /> Please print or type.(Form d�gned for use on elite f12—pitch)—typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 enerator ID Number �/ / 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST A L 0002 r;—! 7k'600$$$$p 0 3 JJ K <br /> 5('pnPrAtMH Na and MA oino Address Cena toe.Sito Aodraoc('rf diftcrcntlhog mating pddre ) - <br /> Generator's Phone: <br /> 6.Transporter I Company Name U.S.EPA ID Number <br /> 7.Transporter Company Name U.S.EPA IDNumber <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> . C. <br /> Facility'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(d any)) 13.Waste Codes <br /> No. Type Quantity WtNol. <br /> 1. <br /> ILI <br /> 2. <br /> LU <br /> O <br /> 3. <br /> i <br /> 4 <br /> I <br /> 14.Special Handling Instructions and Additional Information <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby deciam that the contents of this consignment are fully and accurately described above by the proper shipping name,ardare 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 /> Generafoes/Offeror's Printed/Typed Name Signature Month Day Year <br /> j 16.International Shipments- <br /> g ❑Import to U.S. ❑Export from U.S. Port of entryleA: <br /> Z <br /> Transporter signature(for exports only): Date leaving U.S..- <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> F <br /> Transporter 1 Printed/Typed Nam SignatWei, Month Day.. Year <br /> Cf) _ <br /> ZQ Transporter 2 PrintediTyped Name Signatufe Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ QuantityT ❑ ❑Full Rejection <br /> ❑Type Residue Partial Rejection ) <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> ..t <br /> U <br /> -'n i L�L' Facility's Ptrone: <br /> LU 18c.Signature of Altemate Facility(or Generator) In Day Year <br /> Q <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> C 1. 2. 3. 4. <br /> Fned <br /> d Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in item 18a <br /> Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />