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Pleasg print or type.(Form designed for use on elite(12-pitch)typewriter.) • Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 14,Manifest Tacking Number �/ <br /> WASTE MANIFEST 10"D 1h /' � 41 <br /> ? SKS <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Generator's Phone'. <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> T.Facility's Phone: <br /> gra 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity WLNol. <br /> our <br /> K <br /> a. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information tro ? <br /> I <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and am dassitied,packaged, <br /> marked and Iabelediplacarded,and are in all respects in proper condition forbranspod according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I codify 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 21(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> GeneratoeslOfferor's Printedrryped Name Signature Month Day Year <br /> 16,International Shipments <br /> F - ❑Import b U.S. ❑Export from U.S. Pod of entry/exit: <br /> Transporter signature(for exports only): Date leaving ll5.: <br /> W17.TmnspoderAcknowtedgmentof Receiptof Materials <br /> Transporter-1.Pdnted/Typed Name Signature _ Month Day Year <br /> 4 one <br /> Tmnspr 2 Prints7y-ped Name Signal a - - Month Day Year <br /> -C <br /> 4. 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number'. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> 41 uE <br /> Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. 2. 3. 4. <br /> 0.n <br /> Designated Facility Owner or Operator:Cedifcalion of receipt of hazardous materials covered by the manifest except as noted in Item fee <br /> 1 P nted Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previouseditions are obsolete. GENERATOR'S INITIAL COPY <br />