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Pleasea (Form designed for use on elite (12 pitch) typewriter.) Form Aooroved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />13 <br />NTP <br />•MENT <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Man ifjt T c/ki°�u$m,&er <br />WASTE MANIFEST <br />5. Generator's a and Mailing Address E , f Generator's Site Address (if different than mailing address) <br />- <br />Generator's Phone: <br />6. Transporter 1 Company Name U.S. EPA ID Number ONM <br />ve -. <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 />i;v tit, q t'i.'��E:. fit'4iji, %1}N. <br />ai*, Of%SAW 2,;A ,:'9 i41 <br />Facility's Phone: <br />ga <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />oa <br />LJ <br />i�%l�Oi�%if�� <br />t9�3 ' <br />3. <br />=•i07 <br />- <br />4. <br />lif£ f <br />14 Special Handling instructions and Additional Information <br />�+ ._ � ' ' r'• �{r� X �, "� a::g'� t"� y "°' s'/�' <br />��i � �� � <br />kir f� ,,r% u_ <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br />marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international 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 EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (•f I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />Generator's/Offeror's Printedfryped Name Signature Month Day Year <br />F— <br />16. International Shipments <br />❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: <br />Transporter signature (for exports only): Date leaving U.S.: <br />LU <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Printed(ryped Name Signature..- -. Month Day Year <br />: , <br />CL <br />ZZ <br />Transporter 2 Printed/Typed Name Signature Month Day Year <br />H <br />18. Discrepancy <br />18a, Discrepancy Indication Space ❑ Quantity Type Residue 1:1 Partial Rejection ❑Full Rejection <br />Manifest Reference Number: <br />181b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J_ <br />V <br />LL <br />Facility's Phone: <br />W <br />18c. Signature of Alternate Facility (or Generator) <br />Month % Day Year <br />Z <br />H19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />C <br />1. <br />2. <br />3. <br />4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printed/Typed Name Signature Month Day Year <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />13 <br />NTP <br />•MENT <br />