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Please orint or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.ONIB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator 10 Number. 127Page Page 3....Emergency Response Phone 4.Manifest Tracking Number <br /> G <br /> WASTE MANIFEST BF <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> Generator's shore. <br /> 6.Transporter 1 Company Name U.S.EPA 10 Number <br /> 7.Transporter 2 Company Nam U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Facility's Ph-one: <br /> 98. 9b.U.S.DOT Description fink uding Proper Shipping Name,Huard Class,0 Number, 10.Containers 11.Total 12.Unit 13.Wsle Codes <br /> HM and Packing Group(if any)) No. Type Quantity wtivol. <br /> aC LJ( <br /> 2. <br /> Uj <br /> 3. <br /> 4. <br /> IV1 pas q, C <br /> �,e appropri, <br /> permit for, and wig <br /> 1 le Wdsts 15 <br /> 14 Special Handling Insinictians and Additional Information <br /> shipping. <br /> 15. GENERATOR'SlOFFEROR'S CERTIFICATION: I hereby declare lhatlhe contents of anis oo-isignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marhec and labelediplacarded,and are in 311 respects in proper condition for transport according to applicable international and national govemmental regulations.If export sh pment and I arr the Primary <br /> Exporter,I certify that the content of this consignment conform to the terms of the aaached EPAAcknovoledgment 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)(ifI am a small quantity generator)is true. <br /> Generator'sfOfferor's Prmted)`Typ�d Name Sigpe7e i Month Day Year <br /> -j 16.International Shipments <br /> 1— ::1 Import to U.S. F-1 Export from Pon of enVexit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> LLJ 17.7ransponer Acknowledgment of Recoe�pt of Materials <br /> Transporter'Prinjod/Typed Name Signatux, Month Day Year <br /> orCool <br /> Transporter 2 Printed!-yood Name' S@raUe 'Month Dar--Year <br /> 18.Discrepancy <br /> I Be.Discrepancy Indication Space ElQuantity F Type 0 Residue E1Pallial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> >- 18b.Alternate Facility;or Generator) U.S.EPA ID Number <br /> U. Facility's Phone: <br /> Ljj 18c_Signature cf Afteriate Facility(or Generator) Month Day Year <br /> 05CD <br /> 19.Hazardous Waste Report Management Method Codes(.e.,codes for hazardous waste treatment,disposal,and re-,yding systems) <br /> Uj 1 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification or receipt of hazardous ma'.,erials covered by the manifest except as noted in Item 1 Be <br /> PrintedlTyped Name Signature Month Day. Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> DESIGNATED FACIL M" 'V"GEMERiA.7. <br /> C966-8Lt-60Z BJ19AI!S nod 86t,:L 1 60 9 6 090 <br />