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print or type. (Form designed for use on elite (12 -pitch) typewflter.) Form Approved. OMB No. 2050-0039 <br />UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4 Manifest Tracking Number <br />N)ASTE MANIFEST <br />i J rk <br />5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />GenemioW Phones� <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />7 <br />4. <br />10. Containers 11. Total 12. Unit 13, Waste Codes <br />No, Type Quantity Wt.Nol. <br />4. <br />15. GtNtRAT-OR'S16FFtRdW!S-CE'kT]FICA-TION: I hereby declare that the <br />a 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 terrrs of the attached EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if.1 am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />Gaperatq eslOfferors PrinfledfTyped Name Signature Month Day <br />=j 16., International Shipments <br />I.- [Import to U.S. El Export from U.S. Port of entry/exit: <br />9 Transporter signature (for exports only): Date leaving U.S.: <br />UW 17. Transporter Acknowledgment of Receipt of Materials <br />E2 Transp?rtarl Printedrryped Name SignsWfe Month Day <br />0 <br />CL <br />co k <br />Z T61-isporter 2 Printed/Typed NameDayth <br />Sionalldre Mon <br />18. Discrepancy <br />.18a.Disvepan-cyln-d'ic,a,flonSpor,e.Quan'-----E1Type FIRid, -01"1011IR111don Full-Rejd.1- <br />1 8b. Alternate Facility (or Generator) <br />Facilitys Phone: <br />uj 18c. Signature of Alternate Facility (or Generator) <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />C3 Uj 1 2. 3. <br />20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />PrintedrTyped Name Signature <br />U.S. EPA ID Number <br />4. <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />