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<br />Please prim! or type. (Form designed for use on t'tile (12 -pitch) typewriter.]
<br />Form Acoroved. Otd19 No. 2050.0039
<br />EPA farr1rt' 8700-22 (Rev. 3.05] PrevIoUs editlons are obsolete.
<br />GENERATOR'S INITIAL COPY
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<br />UNIFORM HAZARDOUS
<br />1. Generalcr ID Number
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<br />2. Page of
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<br />3. �merg�rt�y R sponse Ahorle , 4,. nis a in N b �(
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<br />WASTE MANIFEST
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<br />5.'Generataes Name and Mailing Address Generators Silo Address (if different than mailing address)
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<br />Generators Phone: ''•'
<br />6. Transpol'frter.'I Corr�an� NarU.S. EPA ID Number
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<br />7. Transporter 2 Company Name U.S. EPA 10 Number
<br />8. Designated FacllityName and Site Address (',f l s)r'f l.fl'1(.)y'Stj,j. U.S. EPA ID Number
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<br />%ali s Phone:
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<br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Numb%
<br />10. Centalners
<br />11. Tatal
<br />12. Unit
<br />13. Waste Codes
<br />No.
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<br />and Packing Group (if any))
<br />Quantity
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<br />14. Special Handling Instructions andAddiiionalInformation Vis:: id j" j';' °arc.;7f';'s 4
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<br />15. GENERATOR'SfOFFEROR'S CERTIFICATION: I hereby declare #hat lire contents of this consignment are fully and accurately described above by qe proper shipping name, and are classified, packaged,
<br />marked and labeledlplacaided, and are In all respects in proper condition for transport according to applicable International and naftaal govemmentaf regulatlons. If expert shipment and I am the Primary
<br />Exporter, I certify that the contents of Itis cons'gnment conform to the terms of the alladied EPAAcknDw[edgmentof Consent.
<br />I certifylhat Iha waste minimizatfcn stalemerd fden0fied in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (fill am a small quantify gogora• Is tare. ,
<br />GenerolotsfOfferorsPrinledlTypedName Signature ', ? s"` Month, i �� Year
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<br />'16. international Shipments
<br />❑ fmpod to U.S. ❑ Export from U.S. Part of entrylexit:
<br />Transporter signature (for exports only): Dale leaving U.S.:
<br />17. Transporter Acknowledgmenid Receipt of Materials
<br />Transporter 1PdaledrrypedName signature ra r" Month day Year
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<br />Transporter 2PdntedflypedName Signature•` `" Month Day Year
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<br />16. Discrepancy
<br />18a. Discrepancy tndication Space ❑ Quantity ❑ Type ❑ Residuaj El Full Rejection
<br />❑ PeRiat Rejection
<br />Manifest Reference Number:
<br />18b. Alternate Facility (or Generator) U.S. EPA ID Numher
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<br />Facility's Phone:
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<br />18c. Signature ofA€temateractlity(or Generator) Month Day Year
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<br />Hazardous Waste Report Management Method Codes (I.a., codes for hazardous waste treatment, disposal, and recycling systems)
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<br />4.
<br />20• Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifast except as noted In Item 188
<br />PrintedrTyped Name Signalure Month Day Year
<br />EPA farr1rt' 8700-22 (Rev. 3.05] PrevIoUs editlons are obsolete.
<br />GENERATOR'S INITIAL COPY
<br />SIT
<br />
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