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Please print or type.(Form desicned for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> U+IFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Man st Tracking Number <br /> r.: <br /> t, fi <br /> ' t JJ <br /> WASTE MANIFEST. <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> 1, <br /> } <br /> Generator's Phone: 1= U.S.EPA ID Nqrrthe, 1 <br /> 6.Transporter 1 Company�Name ❑� V <br /> C—1 / <br /> —E. ,.te�y>:. iC �`ktst's.A'.M"�{:.'.�1`i` IiC �.'i•.,;}yis;. <br /> U.S.EPA ID Number <br /> 7.Transporter 2 Company Name <br /> ;:.;; 2009 <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> EN flRIJ%iENT HEALTH <br /> Pr:RVIIT/SERVICES <br /> Facility's Phone: <br /> 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> 9a. No. Type Quantity Wt.Nol. <br /> HM and Packing Group(if any)) <br /> 1. <br /> Z 2 <br /> LU <br /> :. f..i✓� <br /> j <br /> 7 B V. L� <br /> 4. klfur,—,10,4,> ii* <br /> 14.Special Handling Instructions and Additional Information w: <br /> 15. GENERATOR'SIO FEROR'S CERTIFICATION: I hereby declare lh8t 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)(it I am a large quantity generator)or(b)(if I am a small quanfity generator)is true. <br /> Month Day Year <br /> [G�tor's/Offeror`s Printed/Typed Name Signature <br /> 16.International Shipments Import to U.S. ExP❑ ort from U.S. Port of entry/exit: <br /> � ❑ <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> uJ Month Day Year <br /> Signature <br /> Transporter 1 Pr nted Typed Name <br /> O <br /> a <br /> QTransporter 2 Printed(Typed Name Signature Month Day Year <br /> t` <br /> 18.Discrepancy <br /> 18a,Discrepancy Indication Space quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> U.S.EPA ID Number <br /> 181b.Altemate Facility(or Generator) <br /> J <br /> U <br /> ua Facility's Phone: <br /> LO 18c.Signature of Alternate Facility(or Generator) A4onth Day Year <br /> LO <br /> a <br /> Z <br /> 0 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> O 1 2. <br /> T- <br /> 20. <br /> 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 INM AL C ,4P— <br />