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� Please Print or t yp e.(Form desigqed for use on elite(I 2-pitch)typeLA(liter.) <br /> 1 1.Generate,ID Form Approved.01VIS No.2050-003� <br /> UNIFORM HAZARDOUS Number 3.Emergency Response Phone 4.Manifest Tracking Amber <br /> WASTE MANIFES E�M I SKS5 Generat&s Name and I'Aarjng Aci :i�: <br /> Generator's Site Address(f different than m0irg address) <br /> Ganerator's Phone: <br /> 5.7ransporler 1 Company Name <br /> O.S.EPA ID Number <br /> 0.Designated Facility Name and Site Addrass <br /> U S.EPA ID Number <br /> Fadliys Phone: <br /> 9a. 9b.U.S DOT Oe5criplion(incWing Proper Shipping Name,Heard Class,io Number, Contai ers <br /> -LM and Pacldnq Group(if any)) 11 Total 12.Unit <br /> — No. -Type Quarit!"y wl.iVol. 13.Waste Codes <br /> LLJ <br /> 4. <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of th�s consignment are fully and accuralte�y described above by tha proper shipping name,and are das0ed,packaged, <br /> marked ard labLWIpiacarded.and are in all respects 4)proper condition for transport according to appl�cable international and na:iiona�governmental regulations.�fexport shipment and I am the Primary <br /> bporier,I cortfy that the contents ofthis consignment conform to the terms of the ailachad EPA Acknowledgment of Consent. <br /> I cetfy that the waste mirimizator statement identifed in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quartly generator)is true. <br /> Genorator`s�Offeroes PrintediTyped Name Signature <br /> Month Day Year <br /> 0 Inipert to U'S. LJ Export from U.S Fort of 0 tryle�xit" <br /> Transporter signature�for exports only): Date laavfl�ng V.$.; <br /> wi <br /> Month Day Year <br /> CL <br /> ,k 18.Diweparcy <br /> 18a.Discrepancy Indication Space El Quantity El Type R.idu. Elpartii R ejection Full Rejection <br /> Manifest Ref�reriw Number: <br /> 13b.,Vternala Facility(or Generator) U.S.EPA ID Number <br /> iz 19.HazardoLs Waste Report Management Ma�hod Codes(i.e.,ondes forhazardous,waste tr-2atrient,disposal,and recycling systerns� <br /> 20.Designated Facility Owner or Operator:CeMiFicatioi of receipt of hazardous matodi covered by the manifest except as noted in Item 18a <br /> ticuTyped Na.me Signature Mwth Day 'ear <br /> EPA Form 8700-22 <br /> � <br /> � <br /> � <br /> .' ' Previous adit�cns. obsolete, GENERATOR'S INITIAL COPY <br /> ` | <br /> ` <br />