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type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> ORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number I I <br /> WASTE MANIFEST ' J J K <br /> 15.Generator s.Narne and Mai hng,Address ,r =13 ddress(if different than mailing address) i <br /> Generator's Phone: ;t <br /> 6.Trapsporter 1 Company Name U.S.EPA ID Number <br /> ,f <br /> 7.Transporter 2 Company Name U.S.EPA ID Number g <br /> 'a <br /> ;t <br /> 8.Designated Facllity.Name and.Sitd Addt"ess U.S.EPA ID Number G <br /> Facility's Phone: " <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12,Unit <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes p <br /> t <br /> ® t <br /> 2 � > <br /> i <br /> i <br /> - <br /> r,. <br /> V' <br /> 3. <br /> ( <br /> 4. <br /> 3 t <br /> 14.S aLHap0Iing Instructions and Additional Information <br /> k: <br /> 15. GENERATOR'S/OFFEROR'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 t <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 ideptified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(rf l am a small quantity generator)is true. <br /> IF, <br /> Generator's/OfferorS.'Pfjntegdq,y ddNOI,i6 °! ri Month Day Year <br /> rhV, <br /> K Sf1., <br /> 16.International Shipments 1 <br /> t <br /> i— ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> LW 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name Signature ,< ;? Month Day Year <br /> ® F )� <br /> i <br /> F <br /> CO Transporter 2 Printed/Typed Name Signature Month Day Year <br /> Q <br /> W <br /> b-- <br /> is <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity El Type ❑Residue ❑Partial Rejection El Full Rejection <br /> Manifest Reference Number: <br /> >- 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> a <br /> U <br /> Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> F <br /> Q <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. a 2. 3 3. 4. <br /> $ 3 <br /> r20,—Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except asnoted in Iteml8a <br /> /Typed Name Signature X, Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. ? f� I NATED FACILITY TO GENERATOR <br />