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Please pintgrtype,{Farr designed ior use on elite(12-)itch)typewriter.) Form Approved.OMB No-205NO39 <br /> UNIFORMHA&MOUS, 1 Geieralor lt)Number 2.Page i of 3.EmergencyResprnse 1'tmne 4,IYlanrfesl Tradung tdranErer <br /> WAMMANr Esr' 9 JJK <br /> 5 Generatoes Name and Mading Address GeneraWs Site Address(it different Man mailing address) <br /> . <br /> Generator's Phone: <br /> 5.Traraporter 1 Company Name U.S.EPA ID Number <br /> A_ <br /> 7.Transporter 2 Company Name U.$.EPA Ip Number <br /> &Designated Fac§pty Name and Site Address U.S.EPA ID Number <br /> 3Cne;�.FA.isv <br /> Faciws Phone 9 2 c; 4 <br /> g� 9b.US.DOT Description(Including proper Shipping Name,Hazard Class,ID Number, W.Containers 11.TotaE 12 Unit 13.Waste Codes <br /> HM and Failing Group(deny}) No. Type Quantity WLry d. <br /> 1. <br /> ;= c. i A A l%R's;,s3 `syyxtµ kc J d`€a �„ r A> <br /> idv 3 4a aP <br /> W - <br /> z 2. . <br /> LU <br /> C9 - <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions andAddi6anal Information <br /> 15. GENERATOWSKJFFEROWS CERTIFICATION'. I hereby dem that the contents of this consignment are fully and acordiely described above by the proper shipping name,and are classified,padceged, <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 l am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of The attached EPAAdmowledgment of Consent. <br /> l certify that the graste.mirdmization statement Identified in 40 CFR 262.27(a)(f ft am a large guan*generator)or(b)(if Ilam a small quantity generator)is true. <br /> t;enera[asf is Ponha ffyped Name ' t Signature Month Day Year <br /> } <br /> `t,. E 4 ,s'• t•3• }� :'i, ,'� �"v .:.. yam' -i~".. <br /> 16.inte�tionhi Shipments - `' <br /> [�- ❑Import to U.S ❑Export from U.S. Pat of enirwe)dt: <br /> z <br /> — Transpatersignature(for exPorts ordy): Date leaving U.S.: - <br /> Il 17.TransporterAdnowledgment of Receipt of Maferiats �+ <br /> Transporter 1 Prarta&TWad Name Signature a' Month Day Yea <br /> zQ Transporter Printedf yped NameMoraih ay; D Year <br /> a � <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection L�J Full Rejeclion i <br /> Manifest Reference Number <br /> 18b.Alternate Fadlify(or Generator) U.S.EPA b Number <br /> Zi <br /> U <br /> U<- FadWs Pham: <br /> tQ 18c.$grmture of Aitemate Fadlily(or G neralor) Month Day Year <br /> Q <br /> z <br /> 19.Hazardous Waste Report ManaWrnerd Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1_ 12- 3. 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manitiest except as noted in item 18a <br /> Pnntcxllfyped Name Sigrrature Month Day Year' <br /> r i. <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. ;eDESIGNATED FACILITY TQ GEi+#ERATOF <br />