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� O L type. (Form designed for use on elite ( 12-pn,.1 ) typewriter. ) Form Approved. ON18 No . 2050-0039
<br /> ,rIIFORM HAZARDOUSFOF
<br /> 4. anifestTrackln Number. ,� . .-
<br /> 1 . Generator ID Number =Gre
<br /> esponse Phone 9 a .
<br /> WASTE MANIFEST t�' f ' } } "' :p. �1 yr ; ' .' `? � tl L �? >,>of ' ) ? r .? FLE
<br /> 5- Ge erafor's Na e a d ailing Address PIT,
<br /> Address (if different than mailingaddress)tof OFF OF
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<br /> Generator's Phone:
<br /> 6. Transporter 1 Company Name U.S. EPA ID Number
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<br /> 7 . Transporter 2 Company Name — U.S. EPA ID Number
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<br /> 8 De i noted Fttt - pili Narne.�nd S to Address U.S. EPA ID Number
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<br /> Facilitys Phone: %mar ' �'
<br /> 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10, Containers 11 . Total 12, Unit 13. Waste Codes
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<br /> Type Quantity Wt.Nol.
<br /> HM and Packing Group (if any)}
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<br /> 1 !. So ci I Handling Instnictlons andAdditwpal Information t 7- i ,? f z OF `
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<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
<br /> Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent.
<br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generaforf or (b) (if I am a small quantity generator) is true.
<br /> rGepuatoes/OfferortsIF
<br /> Printed7Typed Name gnature OF. Month ay Year
<br /> rrol OF OFF I.
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<br /> Or" FI OF OF e:foll,.1 ,'
<br /> l,,J 116, International Shipmentsk
<br /> F 1:1Import to U.S. Export from U.S. Port ofentry/exit:
<br /> Transporter signature (for exports only): Date leaving U.S
<br /> w17, Transporter Acknowledgment of Receipt of Materials
<br /> Transporter 1 Printed,typed Name Signature: Month Day Year
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<br /> z Transporter 2 Printed(Typed Name Signature Month Day Year
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<br /> 18. Discrepancy
<br /> 18a, Discrepancy Indication Space Quantity ❑ Type El Residue ❑ Partial Rejection Full Rejection
<br /> Manifest Reference Number:
<br /> 18b. Alternate Facility (or Generator) U.S. EPA ID Number
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<br /> Facilitys Phone:
<br /> Lo 18c. Signature of Alternate Facility (or Generator) Month Day Year
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<br /> U) 19. Hazardous Waste Report Management Method Codes (i-e., codes for hazardous waste treatment, disposal, and recycling systems)
<br /> 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 /> Printed'Typed Name Signature . Month Day Year
<br /> EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR ' S INITIAL COPY
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