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Please print or type. (Form designed for use on <br />k5G'enerator's <br />IFORM HAZARDOUS 1 Generator ID <br />WASTE MANIFEST <br />Name and Mailing Address <br />'!w4 M* w+ltntt'Artl l.1 �. <br />9:l't <br />1 g (A C41V1.11 <br />tllyt <br />i } <br />!of 3. Emergency Response Phone <br />es Site Al <br />Form Approved. OMB No. 2050-0039 <br />�nBest Tracking Num6Qr <br />( At. AWJ i til(, . <br />e. uesrgnated Facility Name and Site Address U.S. EPA ID Number <br />i11NN Huttt,r dilri. f I t <br />�NJIO Willi L6+04 It f4d Al S <br />lit )-N. (.A P 12 i1) <br />Facility's Phone: <br />ga 9b. U S DOT Description (Including Proper Sh piping Name, Hazard Class, ID Number.t0. Containers <br />HM and Packing Group (if any)) 11. Total 12. Unit <br />t'1 VI,'a<re r'.rvioc <br />f TRANSPORTER'S COPY <br />O <br />1' �a;)tt;�!'F?3,tfi?Ylrrk►lrD t9:" <br />tiQMi{Fi1Wvr*rk:iK1=s► <br />i ype <br />.mey <br />rruvoa. <br />W <br />Z <br />2 <br />W <br />3. <br />r <br />4. <br />14. Spedal Handling Instructions and Additional 10cirmalion <br />15. GENERATOR'S/OFFEROR'S CERTIFICATION: I I <br />marked and labeled/placarded+ and are in all resp <br />reby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br />s in <br />Exporter. I certify that the contents of this consignmi <br />proper condition for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary <br />nt conform to the terms of the attached EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement identi <br />ed in 40 CFR 262.27(a) (If I am a large quantity generator) or (b) (if I am a small quantity generator) is Rue. <br />Generalors/Offerors Printed+Typed Name <br />Signature Month Day Year <br />-j <br />Z <br />16. International Shipments <br />❑ Import to U.S. <br />❑ Export from U S. Port of entry/exit: <br />— <br />Transporter signature (for exports only): <br />— -- <br />Date leaving U.S.: <br />17. ran <br />Transporter sporterAd nowedgment of Receipt of Materials <br />a <br />Transporter 1 PnntedTyped Name <br />Signature Month Day Year <br />ZTransporter <br />2 Pnnted(Typed Name <br />Signature " <br />Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space <br />❑ Quantity <br />❑Type ❑Residue ❑ Partial Rejection ❑Full <br />Rejection <br />18b. Alternate Facility (or Generator) <br />Manifest Reference Number: <br />J <br />U.S. EPA ID Number <br />U <br />LL <br />Facility's Phone: <br />W <br />18c. Signature of Alternate Facility (or Generator) <br />Q <br />Month Day Yea, <br />Z <br />19 Hazardous Waste Report Management Method Codes <br />.e., codes for hazardous waste treatment, disposal, and recycling systemsl <br />LU1 <br />2. <br />3.,4. <br />r <br />20. <br />Designated Facility Owner or Operator: Certification of <br />r eipt of hazardous materials covered by the manifest except as noted in item 18a <br />Prinied/ryped <br />Name <br />Signature > Month Day Year <br />EPA Form <br />8700-22 (Rev. 3-051 Previous ertlitinne Ara nh¢ <br />lam <br />f TRANSPORTER'S COPY <br />