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Please print or type.(Form dgned for use on elite(12-pitch)typewriter.) 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 <br /> JJK <br /> WASTE MANIFEST <br /> 5.Generatq{s Name aid Mailing Address 1 �.. i Generators Site Address(if different than mailing address) <br /> 0: <br /> Generators Phone: <br /> 6.Transporter i Company Nyme U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility NameandSite Od fess U.S.EPA ID Number <br /> F J <br /> Faculty's Phone: ' .r <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> 0 <br /> W <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information '.. <br /> c.trii .. <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: Ihereby 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 labeled/placarded,and are in all respects in proper condition for banspod 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 EPAAcknowledgment of Consent '.. <br /> I cer ily that the waste minimization statement identified In 40 CFR 262.27(a)(If I am a large quantity generator)or(b)(if I am a small quantity generator)is We. <br /> Generator era P' yped Na Signature Month Day Year <br /> J 16.International 5 i In Is. .� <br /> z - Import to U.S. ❑Export from U.S. Pod of enirylexii: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> Ulu 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter LPdgledRyped Name 1Signature Month Day Year '.. <br /> Q , <br /> 0 <br /> Q Transporter Prinled7Typed Name a Signature Month Day Year '.. <br /> K <br /> F- <br /> 18,Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity El Type 11 Residue ❑Partial Rejection El Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> 0 <br /> w Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> ® 1 2, F. <br /> 4. '.. <br /> 20.Designated Facility Owneror Operator.Codification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700.22(Rev.3-05) Previous editions are obsolete. GENEIRATOlR'S INITIAL COPY <br /> , <br />