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Please print or type.(Form designed for use on elite(12-pitchwriter.) - Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phon 4.Manifest Tracking Number <br /> WASTE MANIFEST ��� <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Generators Phone. <br /> 6.Transporter i Company Name U.S.EPA ID Number <br /> 7,Transporter 2 Company area _ U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S,EPA ID Number <br /> Facility's Phone. <br /> 9a. 9b,U.S.DOT Desorption(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12. <br /> HM and Packing Group(if any)) Unit No, Type Quantity Wt./Vol.Unit 13.Waste Codes <br /> O¢ <br /> i <br /> W 2. <br /> ✓9 <br /> 3. <br /> 4, <br /> r <br /> 14.Special Handling instructors and Additional Information <br /> 15. GENERATOR'S/OFFEROR'SCERTIFICATION: 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/placertled,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 hardly that the contents of this consignment conform to the tens of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(d I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> --awl--awl sVitvut s Pulled,I yped Name lgna ure <br /> on ay ear <br /> J 16.Intemalmnal Shipments <br /> ❑Import to U.S. EJExpertfrom U.S. Pod of entry/exit: <br /> Transporter signature(for rts Onl -- <br /> Dateleavin U.S.'. <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Pnmed7Typed Name <br /> ignature Month ay Year <br /> w <br /> QTrensporter2PrinteNTyped Name ignature <br /> a, Month Day Year <br /> j18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> Quantity El Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest F Reference Numbe18b.Alternate Facility(or Generator) r: <br /> J U.S.EPA ID Number <br /> U <br /> Q <br /> LL Facili 's Phone'. <br /> w18c.Signature ofAkemate Facility(or Generator) <br /> Q Month Day Year <br /> z <br /> H19.Hazardous Waste Repos Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 2. 3. 4. <br /> 20.Desgnated Facility Owner or Operator:Certification of recept of hazardous materials covered by the manifest except ns noted in Item 18a <br /> Printed7Typed Name Signature <br /> Month Day In <br /> EPA Form 6700-22(Rev.3-05) Previous editions are obsolete. <br /> DESIGNATED FACILITY TO GENERATOR <br />