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Please pfmt'or type.(Form designed f&0e an elite(12-pitch)typewriter.) Fort Approued <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2 Page 1 of 3 Emergency Response.Phone T4.Mani s"t�Tracktn Number <br /> WASTE MANIFEST t 4.+`• � tf.. r j ;�� � � 2 <br /> Generators"Stte'Add[ess if different Sha <br /> S.Generator s Name and Mi inglddress { n mailing address) <br /> Generator's Phone, <br /> 6 Transporter)Gompsrty Name U S EPA ID Number <br /> 71Transporter 2 Company Name U 5 EPA ID Number " <br /> s � p <br /> B Designated Fac l�tytame,ar)d Site Atldress U.SEPA @ Numbed <br /> Facilitysphone <br /> ga 9b U S;DOT Desdripten{including Proper Shipping Name,Hazard Class ID Number A0,0ontainers, 11 Total ; 12 Unit 13.Waste Codes " <br /> HM'= and Packing Group(it any)} <br /> No, Type Quantity Wt:Nol: <br /> 1CIIP <br /> zzr ' 2 <br /> 3 <br /> 14Speaal"HandlinglnsfruetiontendAdditionallnformatioh <br /> p <br /> 15. GENERATOR`SIOFFEROR SCERT{ tCAT143V I hereby declare that the obntents of this consignment are fully and accurately described above by theproper shipping namer,and are eassi£ed,packaged <br /> marked end laboledTplaaardad and ane�n all respects ir<proper cvndifiori fpr transport according.to applicable,internationaalend:nationa€goventmentalregulations.If export shipment acid I am the Prima <br /> M <br /> .rY ` <br /> Ezpvrter 1 ceitr�}+(hat thercontents of ibis consigtiritent;conitirin to the temisof tris attaohetl:EPAAdknowietlgment of Ccrrsent: - <br /> ettlfytltat ita waste m iiimtxaUon Statement�dertt�f€ed it 40"CFR 262.27(x).(if l am a'€arge.quantity'generator)or(b)(if l am.a small quantity gelierator).is true." <br /> GeneraforslOffero€sPnntedlTypedNa?ne Signature J Month Day Year. <br /> _=+ 16:IntematEcnal <br /> r— 0 Import tv U:S ❑Export from U.S. Port of entryfexit" <br /> Transporter Signa€urs(for exports only}: [late leaving U.S.: <br /> 17.TransporterAclr ovedg het"of Receiptof Materials <br /> LU <br /> QTranspdrter,1 Pr edped Ng )t Signature r a s ° ` Month Day Year <br /> X Transporter 2 Pnnti3dlTyped Name Signature # A Month Day Year <br /> tY FF s ) g r <br /> ��' P. <br /> 18 D' <br /> , <br /> 18a Discrepancy indication Space <br /> Gluantity TYpe: ❑Res€due Portia€Rejection El Full Rejection <br /> Manifest Reference Number; <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> is <br /> La Facility's Phone:" <br /> 1Be.Signature ofAltemate Facility(or Generator) Month Day Year <br /> Q <br /> "19.Hazardous Waste Report Managemenf Method Codes{t e.,codes for hazardous waste treatment,disposal,and recyc€ing systems) <br /> W 1 <br /> 4.: <br /> 20.Designated Facility Cwner or Operator:Cerlificatiorrof receipt of hazardous materials covered by the manifest except as noted in Item 186 <br /> Pn*dl Wed Name . <br /> Signature. Month <br /> month Day Year <br /> EPA Form"8700-22(Rev.3-05) Previous.editions are obsolete, <br />