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Please print or type.(Form designed for use on elite l(I 2-pitch)typewriter,) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1,00flefal""I qum er 12,Pago1of lErmugancyResponsePhone 1 4.Man.Ifast Tracking Numbs-r <br /> WASTE MA11111T t "t., 1, <br /> I 006MK <br /> 151 SS <br /> 5,Generator's Name and Mailing Address Generator's Site Address(if dIfforehl,than mailing address) <br /> a <br /> Generators 06e, <br /> 6.Transporter I Company NaMe U.&EPA ID Number <br /> 1,Transporter 2 Company Name U.S.EPA ID Number <br /> lyt ji, <br /> 8.Designated Facility Name and Site Address I U.S,EPA ID Number <br /> V <br /> Facility's Phone: <br /> go. 9b.U.S.DOT Description(including Prop erShl ping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity WtIN01. 13,Waste Codes <br /> 1. <br /> 0 <br /> 4� <br /> W Z 2. <br /> 3, <br /> 4. <br /> 14.Special Handling Instructions andAddillonal int rma fon <br /> J, <br /> i5; GENERATOR'S101'�EROR'S'C'Ei iFICA711 N: f i6dby de"c1dra Qy66bbd-`aboAVQ lifciiWUIpping name,and are classified,packe led, <br /> marked and labeled/placarded,and are In all nosfiea is In proper condition,for transport accordIng,to applicable internationaland national governmental regulations,If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this con lgnm)nt conform to the terms of the attached EPAAcknovdedgmahl,of Consent. <br /> I certify that the waste minimization statement Ident fled In 40 CFR 262.27(s)(if I am a large quanlitygqn9rator)or(b)(fl am a small quantity generator)Is true, <br /> TenerntoeslOffetoes Printedrryped Name signature Month Day Year <br /> —j 16.International Shipments <br /> Import to U.S. <br /> El Export from U.S. Pod of entrylexl(c <br /> Transporter signature(for exports only): Data leaving U.S.: <br /> 17 TrainsporterAcknowledgmant of Receipt of Meter als <br /> Transporter 1 PrIcitedflyped Name <br /> Signature <br /> Month Day Year <br /> 0 <br /> a, <br /> U) <br /> Transporter 2 P(Intedirryped Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ <br /> Quan IV OType ❑Residue ❑Partial Rejection D Full Rejection <br /> Manifest Reference Number: <br /> i� <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> :3 <br /> L<1 Facility's Phone: <br /> 18c.Signature of Alternate Facility{or Generator} <br /> 4 Month Day Year <br /> W <br /> Z <br /> A 19.Hazardous Waste Report Management Method oodes;(1.9-cades for hazardous waste treatment,disposal,and recycling systems) <br /> lu <br /> ) 1. 1'- 1 3. <br /> 1 <br /> Ll20,Designated Facility Owner of Operator:CoN1111callm of receipt of hazardous materials covered by the manifest except as noted In]ism 18a <br /> PtinteffTyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3.05) Previous editions ae ollsolete. GE.NERATOFI'S INITIAL COPY <br />