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Please print or type.(Farm designed for use on elite(12-pitch)typewriter.) • Form Approved.OMB No.2050-0039 <br /> 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> UNIFORM HAZARDOUS <br /> WASTE MANIFEST - - ' {J G' 1 -,1 .`+ c* "`� i 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 /> Facilites Phone: <br /> ga gb.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers it.Total 12.Unit <br /> and Packing an 13.Waste Codes <br /> HM g Grou pif( 911 No. Type Quantity Wt./Vol. <br /> 1. (- <br /> WA-TC AEI U !L.ti . PLxiVIl'i i t114 j" j(:7. 34 OUT <br /> av F� <br /> w <br /> w FrfCiG DOW <br /> ;X 35:. GUYc <br /> rE1 f LIXE YJI- 't-i ...i-iia+: i' UV02 D006 ieui <br /> k L' t h"Tirl <br /> 4NC11� R".F HA Akly S 4:f :TE L?QLIIDS 0!JT <br /> {NTIr1".HCL1:: 01:L <br /> �)t.I <br /> 14.Special Handling Instructors and Additional information SV TR 11t-i ;A 361 <br /> ETk-41 : ' ''FPGf1 ' . : .5)EPr,111_4 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by me proper shipping name,and are classified,packaged, <br /> marked and Iabeledlplacarded,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 EPAAcknowledgmenl of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)fif I am a large quantity generator)or(b)(if I am a small quantity generator)is We. <br /> Generators/Offerors PnniedrTyped Name Signature Month Day Year <br /> { <br /> 7 16.7em9tional Shipments <br /> f— ❑Import to U.S. ❑Export from U.S. Port of enUylexit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Tmnsponert PrinledRyped Name Signature ;ye.. Month Day Year <br /> O <br /> a t <br /> aTransporter 2 Printed/Typed Name Signature — Month Day Year <br /> rY <br /> 1-- <br /> 18.Discrepancy, <br /> 18a.Discrepancy Indication Space ❑ Quantity El Type ❑Residue ❑Partial Rejection ❑Full Rejecfion <br /> Manifest Reference Number: <br /> F 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> w 16c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> V5 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1 2 <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />