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Please punt-or#pe!-Form'designed for use on elite(12 pitch)typewriter.)
<br /> Form Approved,OMB No.2050 0039
<br /> 1.Generator ID Number 2.Page 1 of 3 Emergency Response Phone 4.Manifest TrackingyNumber v
<br /> UNIFORM HAZARDOUS c-�F , , r t'.: x:t,.,Ti,� �f3. w>y JJ i�
<br /> WASTE MANIFEST
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<br /> �?Generatoes SiteAddress(if different than mailing address)
<br /> 5 Gen�arat is�a er Dd Mailing Address
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<br /> Generators Phone: `�' 443ra::
<br /> �.,. �; US EPAID �urabrt t s
<br /> 6,Transporter 1 Company Nam
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<br /> U,S EPAIDNumber
<br /> 7 Tfansporter 2 Company tJa�ne "f r
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<br /> 8.Dejiggate. Fa i,ty ar�errS(te Address A R•N4 k
<br /> v�� , U.S EP IQ.N m1 err,,�,j
<br /> Facility's Phone
<br /> 9b.U.S.DOT Description(including Proper Shipping Name,,Hazard Class,;ID Number' I 10.Containers,,,•,.t, z' ,,.,11 Total, : ,12'.Unit 13 Waste Codes
<br /> 9a. Quantity Wt Nol.
<br /> HM and Packing Group(if any)) No. Type
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<br /> 14.S ectal Handling Instructions and Additional Information
<br /> 15, GENERATORWOFFEROR'S CERTIFICATION; I hereby declare that the contents of.thisconsignment are fully and accurately described above by the proper shipping name,and are classified,packaged,
<br /> marked andlabeled/placarded;and are in all respects in proper condition for transport aocordinb 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 terns of the attached EPAAcknowledgment of Consent.
<br /> I certify that the waste minimization statemen(identified in 40 CFR 262,27(a)(if I am a large qu4ntity generator)or(b)(if Fern a small quantity generator)is true. Month Day Year
<br /> Generatorsl0fferors Pdnted/Typed llama, Signature- gg
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<br /> ri 16.international Shipments Import to U.S, ❑Exp1 0 from U.S. Port of entrylexit:
<br /> I— Date leaving U.S.:
<br /> z Transporter signature.(for exports only)`. �,
<br /> W 17,TranspoderAcknowledgment of Receiptof Materials - • r ' r
<br /> w Signature J' ��' ✓ Mo Lear
<br /> Day
<br /> Transporter 1 Printed a Name I a� J py
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<br /> a ' � r Month Dal
<br /> Year
<br /> Transporter 2Name Signature
<br /> -Pdntedffypad
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<br /> ~ 18.Discrepancy
<br /> 18a.Discrepancy Indidation Space E quantity ❑Type I ❑Residue O'partial Rejection ❑Full Rejection
<br /> Manifest.Reference Number:
<br /> 18b.' temate Facility(or Generator) U.S.EPA ID Number
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<br /> Facility's Phone; w Month Day Year
<br /> W Ise.Signature of Alternate Facility(or Generator) �< a
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<br /> .19.Hazardous Waste:Repod Management Method.Codes(I•e„codes for hazardous waste treatment,disposal,and recycling systems)
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<br /> 20.DesignatedfacilltyOwner or Operator:Certification of receipt of hazardous materials covered by the manifest except as not ed In Item 18a
<br /> Pdnted/ryped Name Signature Month ay Year
<br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. TRANSPORTER'S COPY
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