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Pleas@ print or type. (Form designed for use on elite (12 -pitch) typewriter.) Form Approved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05)—Pmvious editions are obsolete. GENERATOR'S INITIAL COPY <br />UNIFORM HAZARDOUS <br />1. Generator ID Number2. <br />Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />t ' <br />014644492 J J K <br />WASTE MANIFEST <br />04 u 1 <br />E' G, <br />5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />_ <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. Designated Facility Name and Site Address U.S. EPA ID Number <br />_ r <br />A t F <br />Facility's Phone: <br />ga <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />Y <br />LU2. <br />^ <br />IRnNMENTAL HEALTH <br />a. PERMIT/SER <br />14. Special Handling Instructions and Additional Information <br />tt,•.,.i t: i e .�l:� �' Y;ia..ir.�l;i'�' � e''u��. .3�it3F;�isy` ���'tf��:+�'1;ilft:'•`z` t'.�{'l'i=;/;'t',", ��1f3'�f1-t �..'_, <br />tea.. - <br />_. ... •. '� r• - + .. ySps <br />.SS .Trt r�r �.�. <br />15. GENERATOR'SIOFFEROR'S 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 labelediplacarded, 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, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />Generators/Offerors Printed/Typed Name Signature r ; Month Day Year <br />f <br />16. International Shipments <br />❑ Import to U.S. ❑ Export from U.S. P6rt of entrylexit: <br />Z <br />Transporter signature (for exports only): Date leaving U.S.: <br />LW <br />17. Transporter Acknowledgment of Receipt of Materials <br />iY <br />-- <br />Transporter 1 Printedffyped Nam err^' . Si,.^,.azure =� Month Day Year <br />Z <br />Q <br />Transporter 2 Printed/Typed Name Signature Month Day Year <br />W <br />F- <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Partial Re ❑ Full Re' <br />❑ Residue Rejection lection <br />Manifest Reference Number: <br />F� <br />181b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />U <br />Facility/s Phone: <br />w <br />18c. Signature of Altemate Facility (or Generator) <br />Month Day Year <br />Q <br />z <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />0 <br />1. <br />2. <br />3. <br />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 />Printed/Typed Name Signature Month Day Year <br />EPA Form 8700-22 (Rev. 3-05)—Pmvious editions are obsolete. GENERATOR'S INITIAL COPY <br />