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Please print or type.(Form designed for use on elite(12-pi ewriter.) �./ <br /> 1.Generator ID Number Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 2.Page 1 0! 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) F LE <br /> Generators Phone. <br /> 6.Transporter 1 Company Name <br /> US.EPA ID Number <br /> 7.Transporter2 Company Name <br /> U.S.EPA ID Number <br /> 6.Designated Facility Name and Site Atldmss <br /> U.S.EPA ID Number <br /> Facilitys Phone. <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, <br /> HM and Packing Group(if any)) 10.Containers 11,Total 12.Unit <br /> 1 No. Type Quantity WtNol. 13.Waste Codes <br /> d' <br /> W <br /> rJ <br /> w i <br /> 3. <br /> 4. <br /> 3 <br /> 14.Special Handling Instructions and Additional Information <br /> 15, GENERATOR'SIOPFEROR'S CERTIFICATION: (hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classifieQ packaged,Primary <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable intemahonal and national governmental re . <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. gulationsIf export shipment and am the <br /> 1 certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generates)or(b)(if I am a small quantity generator)is true. <br /> Generators) erors Pnnletl ypetl Name <br /> gnature <br /> on aY ear <br /> 18.International Shipments <br /> 2 ❑Import to U.S. ❑Export from U.S. Port of entry/exit. <br /> Trans ones signature for exports onl '. _ <br /> W 77.Transporter Acknowledgment of Receipt of Materials Date leavin U.S.: <br /> OTansporter 1 PrintedlTyped Name <br /> ignature Mon <br /> Z ay ear <br /> Q Tmnsporter2 PrinretlfTypetl Name <br /> ignalure Month Day Year <br /> Ep <br /> ancypancy Indip(ion SpaceQuantity Type Residue ❑PaNal Rejection Full Rejegion <br /> te Facility(or Generator) Manifest Reference Number <br /> one: <br /> re of Alternate Facility(or Genera tor) <br /> Z Month <br /> gForm8700-22 <br /> te Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 2.hty Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> SignaWreMonth DayYear <br /> EPA 8700-22(Rev.3-05) Previous editions are obsolete. <br /> GENERATOR'S INITIAL COPY <br />