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Plase print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1-GeneralorlD Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST 4 '76 J J K <br /> 5.Generator's Name and Mailing Address <br /> Generator's Site Address(if different than mailing address) <br /> Generator's Phone:.'V4 <br /> S.Transporter I 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 10 Number <br /> -7 <br /> Facifil(s Phone: <br /> 9a. 9b-U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 111.Total 12-Unit <br /> HA,j and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes <br /> i. <br /> 0 <br /> al <br /> 2. <br /> Uj <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately dazz;ribed above by the proper shipping name,and are classified,packaged, <br /> marked and labeleditplacarded,and are in all respects in proper condition for huspud according to applicable international and national governmental regulations.11'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)fil am a small quantity genera"is true. <br /> Generatoes/Offeror's PrIntWyped Nam Signature Moth &Y- Year <br /> --r18. <br /> 16.International Shipments <br /> F- . ; E!Import to U.S. El Export from U.S. Part of entrylexit <br /> a Transportersilihature(for exports only): Date leaving U.S.: <br /> 7L 17.Transporter Acknowledgment of Receipt of Materials <br /> Lj <br /> Transportorj PrintedlTyped Name Signature Month Day Year <br /> Z I I ransponer 2 PnntedfTyped Name Signakire-- Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy.Indication Space El Quantify 1:1 Typ. F-1 Residue 0 Partial Rjectio. El Full Rejection <br /> Manifest Reference Number., <br /> 18b-Alternate Facility(or Generator) U.S.EPA ID Number <br /> I&- Facility's Phone: <br /> LO 18c.Signature of Alternate Facility(or Generator) Mordh Day Year <br /> R <br /> ! <br /> Z <br /> U <br /> 0 <br /> V5 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatmeK disposal,and recycling systems) <br /> 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18& <br /> PrintedfTyped Name Signature month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. TRANSPORTER'S COPY <br />