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Please print or type.(Form designed For use.orf elite(12-pitch)typewriter,) --'Form Approved.OMB No,205MO39 <br /> UNIFORM HAZARQOUS 1 Generator lD Nrtmber 2'Page 1 of 3,Emergency Response Phone <br /> f MANIFEST r -.. a,lanlest Trac ng Nwnber <br /> WASf <br /> Generators Name and.Ma lng Addes01749711 <br /> JJ K <br /> eneraorg,$te <br /> Address{ddtfferent than mailing address) <br /> e <br /> Generators Phone: x fl,n` "M> ,t s1.1 e h 5R�;; h ?.r. .. q `- .;; s-} ' +. <br /> .� {:': <br /> B.Transporter 1 Company Ngde U.S:EPA 1(?1 Eurgber <br /> T.Transporter 2 Company Name U.S.EPA Id Number <br /> a+'-• <br /> .8.Designated Fadity Name and Site Address x U.S.EPA IG Number <br /> ,K <br /> Facility`s Phone: - <br /> ga• W U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 1Q.Containers 11.Total 12Unit <br /> HM and Paeking Group(If any}] ; 13.Waste Codes <br /> NO. Type Quantity Wt.Nol. <br /> a1. -- .. ., � .•k..1 is �;��!•.• ;+, � _ V _ - �� <br /> • t..6 rr,j �� 7 J � _ c <br /> 2 2. <br /> �u <br /> >:7 <br /> 3. <br /> i <br /> 1 <br /> i <br /> %$pedal Handling Inknuctons.and Additional Information <br /> 15. GENERATOR'SIOFRROR'S CERTIFfCATION: I hereby declare that the content§of this consignment are fully aad'acaurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacardad,and are in all respects in proper condition.for transport according to applicable intemadDrW and national govemmental regulations:If export shipment and 1 am the Primary <br /> Exporter,I cert fy that the contents of this consignment conform to the temts of the attached EPA Admowledgment of Consent <br /> I certify that the waste minimization statement identified in 40 CFR 262X(a)(I I am a targe quantity generator)or(b)(it I am a small quantity generator)Is true, <br /> Generatars(Offeror's Printed)Typed Name Signature Month flay Year <br /> F 16.International Shlpmenls ❑Import to U.S. - <br /> Z � ❑Export from U-S. Part ofentrylardt. <br /> -- <br /> Transporter signature(far experts only): Date leaving U.S.: <br /> W 1T.TransporterAcknowledgrnentof Receipt of Materiafs <br /> Transporter 1 PrintedlTyped Name Signature f Month flay Ycar <br /> Transporter 2 PrintedlTyped Name Signature 4 <br /> Month Day Year <br /> h- <br /> Is,Discrepancy <br /> 18a.Discrepancy Indlcafion space ❑ Quantity ❑Type YP ❑Residue ❑Partial Rejection ❑Full RejeLtnn <br /> r' <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U-S.EPA ID Number <br /> V <br /> ua. F-dlitysPhone: <br /> 18c.Signature of AHamate Facitity(or Generator] <br /> Month Day Year <br /> a <br /> Hazardous Waste Report Management Mal hod Codes(ie.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 2• g R <br /> 20,Designated Facility Owner or Operator.CerHeation of receipt of hazardous materials covered by the manifest exceptas noted In Item 18a <br /> ntedlTyped Name Signaw �t Monjh Day_ Year <br /> 1 <br /> EPA Farm 8700-22(Rev.3-05) Previous editions are obsolete. 1 RAFVSRORF>=R'S COPY <br />