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Please print or We.(Form designed for use on elite 12-pitch)typewi ter.) Form A loved.OMB No.2050-0039 <br /> UNIFORM HAZAROOU$ 1.Generator ID Number 2.Page 1 of 3.EmergencyResponse Phone 4.Mennst Tracking Nu user <br /> WASTE MANIFEST S V Q <br /> S.Generators Name and Meiling Address Generators She Address(tfdifferent than mailing address) VKS <br /> Generators Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Facili sPhme: <br /> 9, Qn.U.S.DOT Description(Including Roper Shipping Name,Hazard Clasp,ID Numbe 10.Comet em 11.Tore) 12.Unit <br /> HM 1.and Packed Group(If any)) No. Type Quantity W WoI. 13.Waste Cutles <br /> K <br /> aO <br /> C <br /> 2 2. <br /> W <br /> rJ <br /> 3. <br /> 4. <br /> 14.Special Harling instructions and Additional Nformabon <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the Contents of this CoMgnman are fully and acauralely described above by the proper shipping name,and are classified,perksged, <br /> marked and labeledlplecareed,and are in all respects In proper condition M transport according to applicable information] national governmental regulators.If export shipment and I am rine Primary <br /> Exporter,i cerrilyBrat the contents of this consignment conform to the terms of the attached EFAAcluww9edgment of Consent. <br /> I CA"Al waste minimization statement Identified in 40 CFR 26217(a)(if I am a large quantity generator)or(b)(dl an,a small quantity generator)is we. <br /> GenesuorstOgemrs Pdntedrryped Name Signature Mont Day Year <br /> F 16.International Shipments ❑ <br /> = Impwt b U.s. ❑Expert form U.S. Pmt ofenayt M; <br /> Transporter signature(for export only): Date leaving UA: <br /> 17.TransporlerAdinowledgment of"t of Materials <br /> OTransporter 1 PdntedRyped Name Signature Month Day Year <br /> a <br /> N <br /> Transporter 2 Pdntedrryped Name Signature Month Day Year <br /> 1e.Discrepancy <br /> life.Discrepancy Indication Space ❑ 0vaneYy, ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Mandell Reference Number: <br /> tab.Asemate Facility(or Generator) U.S.EPA ID Nwrber <br /> 7 <br /> V <br /> ua. Facillys Phan.: <br /> aB 18S Sgnsture ofAfternate Facility(or Generator) Month Day Year <br /> 2 <br /> N19.Hazardous Waste Report Management Method Codes(i.e..codec for hazardous Coasts aeatment,disposal,and recycling systema) <br /> G 1. 2. 3. 4. <br /> 20.Designated Facility Owner or 00amtor.Cerafiation of receipt of hazardous materials covered by the manifest except as Med in gem lits <br /> Pdntedrryped Naos Signature Wish Day Year <br /> EPA Form 6700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />