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R? <br />pinnui type. krunnuasigneu j(K use on erne (I&pi=) <br />rypewrner.) t-orrn Approved. UMU No. ZUW-WU9 <br />UNIFORM HAZARDOUS <br />1. Generates ID Number <br />0 11 <br />S. Emergency Response Phone <br />4. Manifest Tracking Number <br />WASTE MANIFEST <br />-.. <br />014789140 JJK <br />76 <br />1 <br />5. Generators Name and MailingAddress <br />Gencritor's Site Address (rfdffmnt than mailing address) <br />Gianerator's Phone: <br />6. Transporter I Company Name <br />U.S. EPA ID Number <br />7. 'rransportef 2 Company Name <br />U.S. EPA ID Number <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />Facilitys Phone: <br />ga <br />9b. U.S, DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10, Containers <br />11. Iota] <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (6 any)) <br />Quantity <br />WL/Vol. <br />0 <br />2 <br />3. <br />a <br />4. <br />a <br />14. Special Handling instructions and Additional Informal= <br />15. GENERATOR'S/OFFEROR'S CERTIFICATION: I "y declare that the contents of this consignment are fully and accurately described above by the proper snipping name, and are 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, ; cerfify M the contents of this cDinsignment'conform to the terms of the allached EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement idenbfi in40CFR 6227(a) (rl' I am a large quantity generator) or (b) (91 am a small quantity generator) is true- <br />Generatries/Offeror's PnntedTFyDed Name Signature Month Day Year <br />=a <br />F- <br />16. International Shipments <br />E] Import to U.S. ❑ Export from U.S. Porta4i`WyIexit: <br />Transporter signature (for exports only): Date leaving U.S.: <br />W17. <br />Transporter Acknowledgment of Receipt of Materials <br />I— <br />Transporter 1 PrintedfTyped Name Signature Month Day year <br />0 <br />U3 <br />;E <br />Transporter 2 Printedfryped Name Signature Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space El Quantity <br />❑Type ❑Residue 0 Partial Rejection El Full Rejection <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />tai <br />Facility's Phone: <br />Lu <br />18c. Signature ofAitemate Facility (or Generator) <br />Day Year <br />Z <br />19. Hazardous Waste Report Management Method Codes (i.i., <br />codes for hazardous waste treatment, disposal, and recycling syste m--) <br />-T <br />2. <br />4. <br />ted Padlty owner or Operator Corthca" of �pt of hazardous rkdedak cQvorQd by the ming�J except as w4ed;n Item i9aF!Nam <br />A Signature �V Month My Year <br />EPA <br />Form 87022 (Rev. 3-05) Previous editions are obsdete. r.r-NFRATnR'S INITIAL COPY <br />