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d,E REF'F7tENCED WASTE WAS RECEN ty. MANDLED AND STORED FOR SV BSEQUEN
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<br />Form Approved. OMB No. 2050-0039
<br />UNIFORM HAZARDOUS 1. Generator ID Number
<br />2. Page 1 of
<br />3. Emergency Response Phone
<br />4. Manifest Tracking Number
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<br />WASTE MANIFEST
<br />;' AU,(ITS GRANTED TO T7{EM. BYTE DEPARTMENT OF TOXIC SUBSTANCE CONTROL, TOGO
<br />5. Generator's Name and Mailing Address
<br />Generator's Site Address (W different than mailing address)
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<br />Generator's Phone:
<br />U.S. EPA ID Number
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<br />6. Transporter 1 Company Name
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<br />7, Transporter 2 Company Name
<br />U.S. EPA ID Number
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<br />S. Designated Facility Name and Site Address
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<br />U.S. EPA ID Number,
<br />14. Special Handling IrAttubtiops and Additional Information
<br />Factlity's Phone• . `- -
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<br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, 10 Number,
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<br />10. Containers
<br />11. Total
<br />12. Unit 13. Waste Codes
<br />No.
<br />Type
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<br />and Packing Group (if any))
<br />Quantity
<br />Wt./Vol.
<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 />tha►,lhe,yro tt mltiimia4ion statement identified m 40,CFR 262.27(a) (if I am a lar9e yuantily generator) or (b) (rf I am a small quantity generator) ss true
<br />„,.I,@.grtify
<br />GeneratoeslOfferor's Printe Typed Name Signature
<br />_+ Month .Day Year
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<br />16. International Shipments
<br />❑ Import to U.S. N ❑ Export from U.S. Port of ehtryiexit:
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<br />Transporter signature (for exports only): Date leav U.S.:
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<br />17. Transporter Acknowledgment of Receipt of Materials „
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<br />d,E REF'F7tENCED WASTE WAS RECEN ty. MANDLED AND STORED FOR SV BSEQUEN
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<br />,,1SPOSAL. TREATMENT OR REUSE CROSBY t OVERTON. INC OPERATES THE FACILM
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<br />;' AU,(ITS GRANTED TO T7{EM. BYTE DEPARTMENT OF TOXIC SUBSTANCE CONTROL, TOGO
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<br />4. jig RESOURLE..CONS ERVATIUN.•AND,RECOVFRY )%CT, OF t?76JOGE-1:1t72
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<br />DEICAL AND STATE RE U' t10 . CROSBY t OvFxrON kkg,' ALL OF THE' NECES3
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<br />s^FRM TS TO ACCEPT T14E REFERENCED WASTE AND ALL THE WASTE HAS SEEN HA
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<br />r'CORDINGLY
<br />14. Special Handling IrAttubtiops and Additional Information
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<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 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 />tha►,lhe,yro tt mltiimia4ion statement identified m 40,CFR 262.27(a) (if I am a lar9e yuantily generator) or (b) (rf I am a small quantity generator) ss true
<br />„,.I,@.grtify
<br />GeneratoeslOfferor's Printe Typed Name Signature
<br />_+ Month .Day Year
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<br />16. International Shipments
<br />❑ Import to U.S. N ❑ Export from U.S. Port of ehtryiexit:
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<br />Transporter signature (for exports only): Date leav U.S.:
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<br />17. Transporter Acknowledgment of Receipt of Materials „
<br />Transporter 1 Printedfryped Name Signature 1v� `'+1
<br />Montha� Dl
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<br />Transporter 2 Printed/Typed Name Signature ✓.
<br />Month Day Year
<br />18. Discrepancy
<br />18a. Discrepancy Indication Space ❑ quantity ❑ Type ❑ Residue
<br />❑ Partial Rejection ❑ Full Rejection
<br />Manifest Reference Number:
<br />18b. Altemate Facility (or Generator) ` '. ` I
<br />U.S EPA ID Number
<br />Facility's Phone 1 L i. ! _ d +-, °
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<br />18c. Signature of Alternate Facility (or Generator)
<br />Month Qay Year
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<br />19. Hazardous Waste Report Management Method Codes (i.e.. codes for hazardous waste treatment, disposal, and recycling systems)
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<br />1 • s
<br />2.
<br />3.
<br />4.
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<br />20. Designated Facility Owneror Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a
<br />signature
<br />PrintedfTyped Name . r ;...} r- 1 g
<br />Month gay Year
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<br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete.
<br />DE-610N.UED FACM7Y TO G-EMERATOR
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