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1 <br /> Please print or type. 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 /> WASTE MANIFEST JJ <br /> i <br /> 5. Generator's Name and Mailing Address Generator's Site.Address (if different than mailing address) <br /> i' <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: . ;?I, + If <br /> ga, 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Total 12, Unit <br /> HM <br /> and Packing Group (if any)) No. Type Quantity Wt.Nol. 13. Waste Codes <br /> 1 <br /> 2. <br /> LU <br /> i� <br /> 3. <br /> 4. <br /> 14. Special Handling Instructions and Additional Information <br /> 15. GENERATOR'SIOFFEROR'S 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 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) (if I am a large quantity generator) or (b) lift am a small quantity generator) is true. <br /> Generator's/Offerors Printed/Typed Name Signature Month Day Year <br /> BB <br /> 16. International Shipments <br /> ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: <br /> Transporter signature (for exports only): Date leaving U.S.: <br /> at 17. Transporter Acknowledgment of Receipt of Materials <br /> LU <br /> Transporter 1 Printed/typed Name Signature Month Day Year <br /> ® I 0 <br /> 2E Transporter 2 Pdnted/ryped Name Signature Month Day dd Year <br /> I I 9 <br /> 18, Discrepancy <br /> 18a. Discrepancy Indication Space El Quantity ❑ Type ❑ ResidueEl j ❑ Full Rejection <br /> Partial Rejection <br /> Manifest Reference Number: <br /> 18b. Alternate Facility (or Generator) U.S. EPA ID Number <br /> LLM Facilitys Phone: <br /> LO 18c. Signature of Alternate Facility (or Generator) Month Day Year <br /> B <br /> 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> co <br /> ® t 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 Ise <br /> Pdntedlryped Name Signature Month Day Year <br /> EPA Form 8700-22 (Rev. 12A 7) Previous editions are obsolete. <br />