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Please Print or g (12-pitch) Form Approved. OMB No. 2050.0039 <br /> p type. (Form designed for use an elitetypewriter.) <br /> UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone ManlfestTraching Number <br /> 4. JJK <br /> WASTE MANIFEST <br /> 5. Generators Name and Mailing Address Generator's Site Address (If different than mailing address) <br /> Generator's Phone: <br /> 6. Transporter 1 Company Name U.S. EPA ID Number <br /> 7. Transporter 2 Company Neme U.S. EPA ID Number <br /> e. Designated Facility Name and SlteAddress U.S. EPA ID Number <br /> Facitlty's Phone: <br /> ga 9b, U.S. DOT Descrption (Including Proper Shipping Name, Hazard Class, ID Number, 10. Contalnam 11 . Total 12. Unit 13. Waste Codes <br /> HM and Packing Group (if any)) No. Type Quantity WLNol. <br /> 1' NUN-RCRA HAZARDOUS WASTE, SOLID (BEAD SiASi ) <br /> 0 <br /> a <br /> rx <br /> z 2. <br /> w <br /> w <br /> 3, <br /> 4. <br /> 14. Special Handling Instructions and Additional Information _ <br /> HEMTREC 1.8004249300 WOES TERMINAL CERES NAERG# 901 : 171 Y PROFILE M 981 . <br /> l " • r-. nbl �S Q,11 D; OPJF ^ ?PP `Opel^ TF pEI"EOMI Pcjt: 'TrlJl\F F 'UIPPIFNV <br /> 15. GENERATORStOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name. and are classife ppackaged <br /> marked and Iabeledlplacarded, 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 unify that the contents of this consignment conform to he terms of the attached EPAAcknowledgment of Consent. <br /> I certify Nat the waste minimization statement identified in 40 CFR 21 (If I am a large quantity generator) or (b) (if l am a small quantity generator) is true. <br /> GeneratoeslOflerors Printedlfyped Name Signature Month Day Year <br /> 16, Intemalional Shipments <br /> F ❑ Import to U.S. ❑ Export from U.S. Port of enuylexlL <br /> Transporter signature (for experts only): Date leaving U.S.: <br /> 17. TrenspoderAcknoxiedgmant of Receipt of Materials <br /> Transporter t PrintedrTyped Name Signature Month Day Year <br /> O <br /> a <br /> Transporter 2 PdntedName Signature <br /> lfyped Month Day Year <br /> C <br /> F <br /> 18. Discrepancy <br /> Its, Discrepancy Indication Space ❑ Quantity El Type El Residue ❑ Partial Rejection El Full Rejection <br /> Manifest Reference Number <br /> 180. Alternate Facility (or Generator) U.S. EPA ID Number <br /> U <br /> LL Facildys Phone: <br /> aW 18c. 9ignature of Alternate Facility (or Generator) Month Day Year <br /> 2 <br /> 19, Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> 0 1 2. 3, 4. <br /> 20. Designated Facility Owner or Operator. Certification of recelptof hazardous materials covered by the manifest except as noted in Item 18a <br /> 11 Pnntedrryped Name Signalure Mori Day Wer <br /> EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. OESIGN.ATED FACILITY TO GENERATOR <br />