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t Please print or type,(Fom)designed for use On elit2'12-p►t, <br /> UNIFORM HAZARDOUS t.Generator Id Number pewnEer. <br /> � <br /> 2.?age 1 of 3.Emergency Response Phone .Ma . klri oNp�royed.ObiB No,2050-0039 <br /> WASFEST 4um bTE MANI ��� , <br /> 5.Generator's Name and-Mailing Address <br /> " J <br /> �Gone3tc AdGrit than <br /> mailing addresA) <br /> JUL 14 2010 <br /> Genera r3 Fhone; <br /> 6.Transporter)Company Name AN J0AQU;)J COUNTY <br /> ' ' �fp+:'+,•a„— _ t; U.S.EPA IDNumDer <br /> f <br /> 7.Transporter 2 Company !—ALTH MPARTMENT <br /> NQrgp J �r.;•: .. <br /> U.S.EFA!D Number <br /> 8.�esignafetl Faculty Name and Slte Address , <br /> EPA ID Numbar <br /> fir; <br /> Fa^iIi s Phone: <br /> ga, 911,U.S.DOT Description(inckrding Proper Shipping Name.HMrd Cl <br /> NM and Packing Group(IT any)} umb , <br /> No,C Type Quant ty Wt:Vol 13. este Codes <br /> (� IDN er, 11.Total 12,Unit <br /> O ;tt:. l»a a•r orttgin W <br /> W <br /> 4. <br /> 14.Spacial Handling Instructions and Additional Information <br /> 15. GENERATOR'S101'I' OR's CERTIFICATION: I hereby declare tha:the contents of this consignment ere fully and accurately deecr Ded 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 aocOrding to applicable Intemational and national govemmer l regulabans.If export ahomem and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknrnviedgment of Consent, <br /> I certify that the waste minimization statement identified In 40 CFR 262.27(a)(if I am a large ouanMy generator)or Ibl(if I am a small quantity generanor)Is II <br /> Generator'slOfferor's Pr(ntedllyped Name Signan:re Month Day Year <br /> —1 16.IntemaUoral Shipments <br /> ❑Import to U S ❑&I from U.S. Port of enlrylexd: <br /> 72 Transporter 5igneture(for oxports only): Dats Ieuvinq U.S' <br /> CC 17.TransporterAcknoModgrrlerrt of Receipt of Materials <br /> Monet Day Year <br /> Frtinsportar1Prnted/TypedName <br /> S•gretpre <br /> Q Trail ter 2 Prnted/Typed Name <br /> Signattire Month Day Year <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space � Quantld ❑Type <br /> ❑Res due LJ Partial Rejection ❑Ful Rejection <br /> Manifest Reference Number: <br /> =PAID Number <br /> 18b.Ah�ntrte Facift)'(cr Generator) <br /> V <br /> I`ts Facility's Prione; Mdnln Day Year <br /> 18c Signature of Alternate Facility(or Generffior) <br /> 19.Hazardous Waste Report Management Method Cp]ea(I.e„codes for hazardous rrsate 1reztrneM,diaposal,and recycling syst”- ) <br /> 1 z 3 4. <br /> 20.pesignatad Facility Owner or Operator:Certification o1 recaipt of hazardous rnatenals covered by the mentl6st except as ntled'n Itam 185 <br /> Prtntednyped Name Signature Month Jay Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />