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arint dr type. (Form designed for use on elite (12 -pit wntec) <br />Form Approved. OMB No. 2050.0039 <br />UNIFORM H RDOUS 1 •Generator ID Number 2. Page 9 of 3. Emergency Response Ph <br />4. Manifest Tracking Number <br />"WASTE MANIFEST <br />5. Generator's Name and Mailing Address Generators Site Address (if different than mailing address) <br />Generator's Phone: <br />6. Transporter 1 Company Name <br />U.S. EPA ID Number <br />7. Transporter 2 Company Name <br />U.S. EPA ID Number <br />8. Designated Facility Name and Site Address <br />U.S. EPA ID Number <br />Fadlit Os.Phone: <br />ga <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers <br />11, Total 12. Unit <br />13. Waste Codes <br />HM <br />and Packing Group ('d any)) No, Type <br />Quantity Wt./Vol. <br />1 ' <br />A <br />UA <br />2. y <br />ur <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: 1 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 govemmental 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 EPAAcknow ledgment of Consent <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) ('d i am a small quantity generator) is true. <br />Generator's/Offeroes Printedtryped Name Signature <br />Month Day Year <br />J 16. International Shipments <br />❑ Import to U.S. ❑ Export from U.S. Port ofentry/exit: <br />I. <br />= Transporter signature (for exports only): Date leaving U.S.: <br />W 17. Transporter Acknowledgment of Receipt of Materials <br />tE TrattsP.orter 1-PdntedlTyped Name .. Signature : " <br />Month Day Year <br />} <br />y ~ <br />. <br />pTransorter 2 Printed(fyped Name Signature <br />ay Year <br />Month Da <br />� <br />rY _ <br />t- <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue <br />❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number. <br />18b.AltemateFacility (or Generator) <br />U.S. EPA ID Number <br />J -r <br />Facility's Phone: <br />LU 18c. Signature of Aitemate Facility (or Generator) <br />Month Day Year <br />CDQ 19. Hazardous Waste Report Management Method Codes (.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />55 <br />® 1 <br />2. 3. <br />4. <br />20: Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />PrintedfTyped Name Signature <br />Month Day Year <br />EPA Form 8700-22 (Rev. 3-05) `Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />