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Please print or (Form designed for use on elite(12• Fch) iter.) Form roved.OMB No.2050-0039 <br /> UNIFORMHAZAIWOUS 11.Generator lD Number 2.Paga t of 3.Emergency Response Phone 14,Man)lesl Tracking Numbtrr <br /> WASTE MANIFEST 5227671 JJK <br /> 5,G000ratots Nano and Mailing Address Generator's Site Address(d different than maft address) <br /> Ge tot's <br /> 6Jransporfer f Cormy Name U.S.WA tD Number <br /> 7 Transporter 2 Company Name U.S.EPA ID Number <br /> 8-Designated Facility Mame and SRe Address U S,EPA ID Number <br /> Facill's Phone <br /> ga. 9b.U S:DDT Daws Mn(induciing Propos Shipping Nams,Hazard Class,tD Numbe(, to,Coalehwrs 1i,Total 12,Unit <br /> HM <br /> and PaddN Group(d any)) m Type ouarruty WtNN. 13.Waste Colas <br /> W 2. <br /> i <br /> l <br /> f , <br /> t <br /> —J — <br /> 4,Special Handling Instructions and Additional Information <br /> 15, GENERATOR'SMFFEROR'S CERnFICAnONr I hereby declare that the contents of this consignment are fully and accurately desaibed above by the proper shlpOV name,and are classified,packaged, <br /> marked and labeledtplacarded,and are In all respects In proper condition for transport according to applicable International and national governmental regulations.If expert shipment and I am the Primary <br /> )xporter,Ice"that the contents of this mnslgnment conform to the terms of the attached EPAAcimmAedgmant of Consent <br /> carafyIha(ihe rote m64mizaWn statement IdentitM in 411 CFR 282.27(x)(ff I am a latge quangty generator)or(b)(N t am l quantity generator)Is We <br /> Generatordniedifyped Name � Month Day Year <br /> p , Signature �y <br /> All <br /> J i6.International Shipments <br /> ❑Import to U.S. ❑Export from U.S. Pat of entrglexlc,.„ ... ...... . ....- _ .......... . .. ,_ <br /> Ei Transporter signature for ex only): Data leaving U S.: <br /> te 17.Tramporter of Receipt of Materials ' <br /> Transporter 1 P Fr ntedlTyped Name Signature Man JiDay Year <br /> ZTransporter 2 Pd tasll"A Name Signature ? Month Day Year. <br /> 18,Oisaepancy <br /> IBe.Discrepancy Indication Spm ❑Quantity [:]Type <br /> ; 0 <br /> YP LJ Residue E_f Partial Reject o r Q Full Rejection <br /> i Reference N mbar. <br /> l8b.Aitemais Facifdy(or Generator) U.S.EPA ID Number <br /> Ca <br /> w Faci s Phone: <br /> w I Ba Signature of Alternate Facility(of Generator) Month Day Year <br /> 4 <br /> 19 Hazardous Waste Report Management Method Codes(i.o,codes for hazardous waste treatment,d' and s arms) <br /> G1, s .... _ 2 _ 3 _ A _ <br /> 26 Dxslgnated Faaxty Omar or Operator,CedhesHon of receipt of hazardous materials covered by the manliest except as noted In item lea <br /> pnm4Tyw Name ( Sgnature Month Day year <br /> t f t <br /> EPA Form 8700.22(Rev.3-05) Previous editions are obsolete. TRANSPORTSR'S COPY <br />