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Pieasp print or type. Form Approved OMS No. 2050-0039 <br /> RDOUS 1 Generator ID Number 2 Page 3 C re g y mruT �esPI 4Manifest� Trackng Number <br /> UNIFORM HAZAJJK MANIFEST <br /> 5- G neratols Najneand Mailing Addres r ;r Generator's Site Address ( f dill amid roar mailingaddress) <br /> Generator's 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 /> ga 91h. 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 (it any)) No. Type Quantity Wt,NoL <br /> 1 ' <br /> E <br /> O <br /> Z 2. <br /> W <br /> t7 <br /> 3. 41 1 <br /> 4. <br /> 14g9g�,citat Handling Instructions and Addihrgppl Information f14 <br /> t <br /> _ <br /> 15. GENERATOR'SIOFFEROWS 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 la reledlplacarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and l am the Primary <br /> Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> Ic rgly that the waste minimization statement idengfied in 40 CFR 262.27(a) (if l am a large quantity generator) or (b) (if l am a small quantity generator) is We. <br /> GeneratorslOfferofs Printedflyped Name Signature 1 i' Month Day Year <br /> 16, International Shipments <br /> [I Import to U.S. Expofrom Pod of enl /exit: <br /> K Transporter signature (for exports only): ' Date leaving U.S.: <br /> M 17. TmnsporterAcknowledgment of Receipt of Materials <br /> Via <br /> Transporter l Pnnted/fyped Name : Signature Month Day Year <br /> a <br /> aza Transporter 2 PrintedRyped Name Signature Month Day Year <br /> K <br /> 18. Discrepancy <br /> 18a. Discrepancy Indication Space ❑ Quantity El Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number: <br /> r 181h. Alternate Facility (or Generator) U.S. EPA ID Number <br /> J <br /> 0 <br /> LL Facility's Phone: <br /> w 18c. Signature of Alternate Facility (or Generator) Month Day Year <br /> Q <br /> Z <br /> N19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treah disposal, and recycling systems) <br /> ® 7 . 2. 3. 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 /> 1 Printed hyped Name Signature Month Day Year <br /> EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />