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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050.0039 <br /> 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> UNIFORM HAZARDOUS "7 <br /> WASTE MANIFEST N <br /> 5.GeneratVs Name and Mailing Address Generator's Site Address(if different 1han mailing address) <br /> Generator's Phone: <br /> 6,Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Facilitys Phone: <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number. 10.Containars 11.Total 12.Unit 13.Waste Codes <br /> HM anti Packing Group(d any)) No. T;;e Quan6:y Jt.h'oi. <br /> t <br /> r� <br /> O <br /> w <br /> z 2. <br /> w <br /> 3. <br /> 4. <br /> 14.Special Handling instructions and Additional Informa4:;n <br /> 5. GENERATOR'S/OFFEROR'S CERTIFICATION:I hereby declare that the contents of this cons 1, are tuliy and a c,f5teiy dasMo a above by the prow sh;pping name,8-C are class;fed,pacfaged, <br /> marked and labeledlomrded,and are in all respects in proper condition for transport according W applicable international and national governmental regulations.if export shipment and I am the Primary <br /> Exporter,I certify Mat the contents of this co signmem conform to the terms of the attached EPAAcknoe4edgment of Consent. <br /> t certify that the waste minimization statement idenntirrzd in 40 CFR 262.27(a)(if 1 am a targe quantity generator)or(b)(it I am a small quantity generator)is true. <br /> GeneraWr`siOfferor's PrintedrTyped Name &gna6xe Month Day Year <br /> °2 16.IMemationai Shipments <br /> ❑Impon W U.S. ❑Export tram i;.S. Port of entry,'axit <br /> Transporter signature(for exports only): Date leaving U.S.; <br /> z 17.TransporterAckwMedgment of Receipt of Materials <br /> p Transporter 1 PrintedtTyped Name Signature Month Day Year <br /> Transporter 2 Printedrfyped Name Signatw- Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑Ouanuty ❑Type ❑Residue ❑Partial Reject. ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility for Generator) U.S.EPA ID Number <br /> r <br /> ci <br /> FaciiitidsPhone: fWr D,, e r <br /> 18c.Signature of Alternate Facility(or Generator,, "' <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> C 1 2 a 4. <br /> 20.Designated Faoih y Owner or Operator.Certification of receipt of hazardous materials codered by the manrfest except as ncled in Item 180 <br /> Pnrdedriyped Name Signature Mona I Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />