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se print or type. (Form designed for use on elite (12 -pitch) typewriter.) <br />Form Approved. OMB No. 2050-0039 <br />UNIFORM HAZARDOUS <br />TE MANIFEST <br />1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response PhoneTbMr0452464 <br />racking Number <br />JJK- <br />5, 5. ator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />Generator's Phone: <br />6. Transporter 1 Company Name <br />U.S. EPA ID Number <br />7. Transporter 2 Company Name <br />U.S. EPA ID Number <br />8. Designated Facility Name and Site Address <br />Facility's Phone: <br />U.S. EPA ID Number <br />ga <br />HM <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />and Packing Group (if any)) <br />10. Containers <br />11. Total <br />Quantity <br />12. Unit <br />Wt.Nol. <br />13. Waste Codes <br />No. <br />Type <br />1. <br />2. <br />3. <br />4. <br />1 it Handling Instructions and Additional Information <br />I <br />15. GENERATOR'S10FFEROR'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) (if I am a large quantity generator) or (b) lift am a small quantity generator) is true. <br />Generator'slOfferor's PrintedrTyped Name Signature <br />Month Day Year <br />16. International Shipments <br />❑ Import to U.S. ❑Export from U.S. Port of entrylexil, <br />Transporter signature (for exports only): Date leaving U.S.: <br />_ <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Prinled/Typed Name Signature <br />Month Day Year <br />Transporter 2 Prinledrryped Name Signature <br />Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ ❑ <br />❑ Quantity Type Residue <br />Manifest Reference Number: <br />❑ ❑ Full Re eclion <br />Partial Rejection j <br />18b, Alternate Facility (or Generator) <br />Facility's Phone: <br />U.S. EPA ID Number <br />18c. Signature of Alternate Facility (or Generator) <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />Month Day Year <br />t�m7 <br />1. <br />2. <br />3, <br />4. <br />ENVIRON FU <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />HEN lJ -1770A Drs fir— <br />Printed/Typed Name Signature <br />Month Day Year <br />Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />X <br />r+ <br />