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Please print or type.(Form designed 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 /> WASTE MANIFESTa. JJI� <br /> 5,Generators Name and Mailing Address "� �•+ <br /> Generators Site Address(if different than mailing address) <br /> Generator's Phone <br /> 6.Transporter 1 Company Name <br /> U.S EPA ID Number <br /> 7.Transporter 2 Company Name U.S EPA ID Number <br /> 8.Designated.Facllify Name and$ite Address ... <br /> U.S.EPA ID Number <br /> Facility's Phone: <br /> 7HMand <br /> U.S DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10 Containers <br /> Packing Group(if any)} 11.Total 12.Unit1. 13.Waste Codes <br /> No. Type Quantity Wt.lvol. <br /> w ' <br /> Z42. <br /> LU <br /> t.7 ! <br /> t E <br /> 3. <br /> 4 <br /> � k <br /> r � <br /> 14 Special Handling Instructions and Additional Information <br /> -J: <br /> kaged, <br /> x .w <br /> sified,pac <br /> 15. GENERATOR'$IOFFEROR'S CERTIFICATION. I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are clas <br /> marked and labeled/placarded,and are in atl respects in proper condition for transport according to applicable intemabonal and national governmental regulations.If export m the pac <br /> Exporter,I eertdp that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent, shipment and I s Primary <br /> I certify that the waste minlmizabon statement identified in 40 GFR 262 27(a)(if I am a large quantity generator)or(b)(WI am a small quantity generator)is true <br /> Generators) is Rdntedffyped Name Signature <br /> Month Day Year <br /> z�j 16 Intemational Shipments ❑ r'Import to U.S. ❑Export from U.S. Port of entrytexit. <br /> Transporter signature(for exports only): Date leaving U.S.. <br /> 17 TransporterAcknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name <br /> ® -, Signature i ftth Day Year <br /> QTransporter 2 Printedlfyped Name s 7 # r <br /> Signature Month Day Year <br /> 18 Discrepancy <br /> 18a.Discrepancy indiption Space <br /> ❑ Quantity ❑Type El Residue <br /> ❑Partial Rejection ❑Full Rejection <br /> 18b-Alternate Facility(or Generator) Manliest Reference Number: <br /> J U.S.EPA ID Number <br /> V <br /> Facility's Phone. ) <br /> I&Signature o lemate Facility(or Generator) <br /> Month Day Year <br /> 7E 11 1 1 <br /> S219 Hazardous Waste Report Management Method Codes(!e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> � <br /> 1. <br /> V <br /> 3 4 <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous malenals covered by the manifest except as noted in Item 18a <br /> PdritedlTyped Name Signature <br /> Month Day Year <br /> r <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> GENERATOR'S INITIAL COPY <br />