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07101/2009 14:00 LANSAS PRODUCTS (FAX)2093398260 P.0051008 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 1.Generator ID Number 2.PageI of 3,Emergency Response Phone 4,Manifest Tracking Number <br /> n <br /> WASTE MANIFEST 0 <br /> JJK_ <br /> 5.Generator's Name and Mailing Address Generaloes Site Address(if different than mailing address) <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 /> 8.D.sIgnajec!.Facllil Naro.e and Site Address U.S.EPA ID Number <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 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity WLIVOL <br /> LLI <br /> 3. <br /> 4. <br /> 14,Special Handling Instructions and Additional Information <br /> 15. GENERATOR'SlOFFERORIS 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 labeled1placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.lfexpod 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)(f I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generatoes/Offeroes Printedrryped Name signature Month` Day Year <br /> !rJ 16.International Shipments <br /> 1:1 Import to U.S. âť‘Export from U.S. Port of entry/exit: <br /> Transporter signalure(for exports only): Date leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter I Prinled[Typed Name <br /> or_ Signature Month Day Year <br /> 0 <br /> Q Transporter <br /> 2 Pdnt--dffyped Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity Type Residue Partial Rejection Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> ti Facility's Phone: <br /> w - 1 1 <br /> Month Day Year 18c.Signature ofAllemate Facility(or Generator) 7 <br /> uiCD <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU 1. 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 /> [7ed Name I Signature Month I Day I Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete, GENERATOR'S INITIAL COPY <br />