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Please print or type. (Form designed for use on elite (12-pia ,pewfiter.) Form Approved. OMB No. 2050.0039 <br /> UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4, Manifest Tracking Number JJ <br /> WASTE MANIFEST <br /> 5§, Generators Name and Mailing Address Generators Site Address to different than mailing outlies) <br /> Generators Phone: <br /> U.S. EPA IO Number <br /> 6. Transporter 1 Cempany Name <br /> 7. Transpoder 2 Company Name U.S. EPA 10 Number <br /> 8. Designated Fadlity'Name Site Address U.S. EPA ID Number <br /> Facility's Phone: <br /> 9a 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, 10 Number, 10. Containers 11 . Total 12. Unit 13, Waste Codes <br /> HM and Packing Group (it any)) <br /> No. Type Quantity Wt.N01. <br /> 1 . 9lAMMAil LIQUID. N .OS. . WE IROLEUhI <br /> z 2. <br /> LU <br /> TII!36"TASTE ST FEP,hS H.�9 He PL �I !:.U.! IE 'J <br /> FuR RP.GVCJPJiTii!_:'Si .' f a1 ; - <br /> L1eIv4El'.I Sl. k:i-.RC _r;:' : C _'. . ' <br /> 3. F I : ; �_ITY I :' H <br /> TI 1 f :;11.111 7 4 1 - i �� iO <br /> P . .. '�U. <br /> 1 f <br /> 4. <br /> 74. Special Handling Instructions and Additional Information <br /> --. r1C1a1116s. .\-k7AlV1L4K%!U AVW IC7YNIHV%L VCHCB r'IRLreaN M.L : "a " rinv ILG M 71F41 : fh."i <br /> n�JT IONAI FPA 47,C) nES : 481 . NOW " APPROPRIATP PERSONAL PROTECTIVE ECUIPMEtTf <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 Miele llplacarded, 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 /> Expoder, I certgy that the contents of this consignment conform la the terms of the attached EPAAcknowledgmenl of Consent. <br /> 1 tartly that the waste minimization statement identified In 40 CFR 262.27(a) (If I am a large quantity generator) or (b) (91 am a small quantity generator) is true. <br /> GenemtofslOfferors PrintedRyped Name oignaWre Month Day Year <br /> F16. International Shipments ❑ import to U.S. ❑ Export from U.S. Pod of entrylexit: .... <br /> Transporter signature (for exY ons only): Date leaving U.S.'. <br /> K 17. TransporterAcknowledgmenl of Rewipt ofMatedals <br /> W 51 attire Month Day Year <br /> � Transpoder 1 PdntetlRyped Name 9^ <br /> O <br /> H SignatureMonth Day Year <br /> Q Transporter 2 Pdntedfryped Name <br /> K <br /> r <br /> I <br /> 18, Discrepancy <br /> 18s. Discrepancy Indication Space ❑ Quantity ❑ Type El Residue ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number. <br /> iab. Altemater Facility for Generator) U.S. EPA ID Number <br /> U <br /> I Facililye Phone: <br /> aW 18c. Signature of Alternate Facility (or Generator) Month Day Year <br /> 2 <br /> 19, Hazardous Waste Report Management Method Codes (i.e., cotles for hazardous waste treatment, disposal, and recycling systems) <br /> 4' <br /> 20. Designated Facility Owner or Operator. Codification of receipt of hazardous materials covered by the manifest except as noted in Item ISo <br /> 11 StgnaWre Manu] way Vear <br /> PdnledRypetl Name 4 i,, - <br /> EPA Form 8700-22 (Rev. 345) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />