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it or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> JFORM HAZARDOUS i.Generator ID Number 2.Page 1 of 3 Emergency Response Phone 4.Manifest Tracking Number c�[c <br /> WASTE MANIFEST _.nS - 00X63517 SKS <br /> 5.Generators Name and Mailing Address Generator's Site Address(it different than mailing address) <br /> Generators 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 /> Facility's Phone: <br /> 9a. 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 Quantify Wt.Noli <br /> 1. <br /> W <br /> 3. <br /> 4, <br /> 14,Special Handling Instructions and Additional Information <br /> 15. GENERATOR'S/OFFEROR'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 o iry that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of C nsent. <br /> I codify that the waste minimi ion statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or (i a small quantity generator)is true. <br /> Generator'stOfferor'sfTme ypery ame Signature ,✓'( Month Day Year <br /> ::i16.Internztionhipm nts <br /> P- 11 Import to U.S. ❑Exparl from LLS. 70 Port of entry/exit: <br /> Transporter signature(for exports only): Dale leaving U.S.: <br /> ILL! 17.Transporter Acknowledgment of Receipt of Materials <br /> ¢ Transporters PrintedlTyped,Name Signature Month Day Year <br /> 4 Transporter 2 PnnledlTy d Name '- Signature Month Day Year <br /> K <br /> H <br /> ♦ 18.Discrepancy <br /> I Sa.Discrepancy Indication Space ❑ Quantity El Type ❑Residue ❑Panel Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> F 1Bb.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> 1 Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> z <br /> H19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> D 1' 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:CeNgcation of receipt of hazardous materials covered by the manifest except as noted in Item 188 <br /> I <br /> PnntedrTyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3.05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />