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Form Approved.OMB No.2050-0039 <br /> •Please print or type.(Form designed for use on elite(12-pitch) 'ter.) 2 page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> UNIFORM HA7ARDOUS 1.Generator ID Number FLE <br /> WASTE MANIFEST Generator's Site Address(A different than mailing address) <br /> 5.Generators Name and Mailing Address _ <br /> Generators Phone: U.S.EPA ID Number <br /> ransporarI ompany ame <br /> U.S.EPAID Number <br /> 7.Tmnsporer 2 Company Name <br /> U.S.EPA ID Number <br /> 8.Designated Fadliry Name and Sde Address . <br /> Facility's Phone: <br /> 10.Containers Total 12.Unit 13,Waste Codes <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, No Type Quantity WI.NoI. <br /> HM and Packing Group('d any)) <br /> 1. <br /> ns f <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> eccuretely described above Me proper iinname,and are classified,packaged, <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare thcon <br /> at The tents of this consignment are Wily and nshppg <br /> marked and Iabeledlpdig <br /> lacarded,and are in all respects in proper conon for transport according to applicable international and national governmental regulations.If export shipment and am the Primary <br /> Exporter,I certify 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(x)(IT I am a large quantity genge8 ae or(b)(IT I am a small quanfdy generator)is true. on ay Year <br /> GeneraWr aro sYnn ype Name <br /> ...a 16 international Shipments ❑Import W U.S. ❑Export from U.S. Port of entry/exit: <br /> zDate leavingU.S.: <br /> Trans orter si nature for ex ds onl <br /> w 17.Transporter Acknowledgment of Receipt of Materials ont ay ear <br /> Transporter 1 PrntedlTyped Name igna re <br /> 7 is <br /> a <br /> ignatureon ay ear <br /> z Transpari Ptlntedilyped Name <br /> 6 <br /> K <br /> 18,Discrepancy <br /> 18a.Discrepancy Indicegon Space ❑❑ Quantity Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manrfest Reference Number. <br /> U.S.EPAID Numher <br /> 18b.Alternate Facility(or Generator) <br /> J <br /> U <br /> LL Facili s Phone: Month Day Year <br /> w i Bc.SignaWre of N mate Facility(or Generator) <br /> Q <br /> a <br /> y19.Hazardous Waste Report Management Method Codes(i.a.,codes for hazardous waste treatment,disposal,and recycling systems) 4 <br /> w 1 2 3. <br /> 20.Designated Facility Owner or operator:Certification of receipt of hazardous materials covered by the manifest except as noted In Item Ise Month Day Year <br /> PrintedlTyped Name Signature <br /> EPA Fonn 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />