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Please print or type. (Form 'designed for use on elite (12-pitch)ewriter. ERATOR ) I UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />1. Generator ID Number 2, Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number <br />JJK <br />Generator's Name and Mailing Address Generators Site Address (if different than mailing address) <br />Generator's Phone: I <br />Transporter 1 Company Name U.S. EPA ID Number <br />I Transporter 2 Company Name U.S. EPA ID Number <br />I Designated Facility Name and Site Address- U.S. EPA ID Number <br /> <br />itiLt bi t. •-• ., I i 4illt_k i 14-0, <br /> <br />.'ilt Atir I. . IL I k IT! 64( .1 , <br />Facility's Phone: .il Ii -• <br />ga. 9b. U.S. DOT Description tincluding Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit FDA and Packing Group (if any)) No. Type Quantity Wt.Nol. 13. Waste Codes <br /> <br />, i •., <br />I <br />I i i .___. _ ' 4 GENI <br />---- <br /> i <br />_. i <br /> <br />Special Handling Instructions and Additional Information <br />. i" { , .4.4 <br />GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classif,ed, paciiaged. <br />marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable intemabonal and national governmental regulations. If export shipment and I am the Primary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowiedgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (0) tiff am asmall quantity generator) is true. <br />Grrators/Offerors Printed/Typed Name Signature Month Day Year <br />1.....--. ' - I ' I I —1 <br />F-- <br />M. Interr.ationa Shipments <br />Import to U.S. Export from U.S. Port of entry/exit: <br />Transporter signature (for exports only) . Date leaving U.S.: TRANSPORTER 17. Transporter Acknowledgment of Receipt of Materials <br />TranoaWer1 Printed/Typed Name Signature - Month Day Year , <br />, - 1 i;'''' I ' I <br />Transporter 2 Printed/Typed Name Signature Month Day Year <br />I I I I NATED FACILITY ---0- 18. Discrepancy <br />Discrepancy Indication Space Quantity Type Residue Partial Rejection Full Rejection <br />Manifest Reference Number: <br />Altemate Facility (or Generator) U.S. EPA ID Number <br />Facility's Phone: I <br />Signature of Alternate Facility (or Generator) Month Day Year <br />I I <br />uil r=i <br />I <br />19. Hazardous Waste Report Management Method Codes (i.e.. codes for hazardous waste treatment, disposal, and recycling systems) <br />1 2. 3. 4. <br />20. Designated Facility Owner Of Operator: Certification of receipt of hazardous materiels covered by the manifest except as ncted In Item 18a <br />Printed/Typec Name Signature Month Day Year I I <br />I I. <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obSolete. DESIGNATED FACILITY TO GENERATOR