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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved:OMB No,2050a 039
<br /> UNIFORM HAZARpOUS 1.Generator ID Number 2,P ge 1'of 3 Emergency Rosponse Phone 14,Manifest Tracking Number
<br /> WASTE MANIFEST !::•l,i:+tri., .1 01698765RJJ
<br /> 5.GeAe(�t�r gtne and Mailing Address Generator's Site Address(if different than mailing address)
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<br /> Generator's Phone: utfrl' ri `,fl'ti;l
<br /> 6,Transporter 11Company Name>',,: U.iS EPA ID Nu er
<br /> 7.Tr norter2Company N Erre U.S.EPA ID Number
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<br /> U,S EPA Iq;
<br /> 8.Des� rlt�,g F)ayjlltyf�(�mg; ,;y4,��{��dress tJru�}be
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<br /> Facility's Phone
<br /> 9 .S.DOT Description(including Proper Shipping Name,Nazard Class,ID Number, Jo,Containers ,: 11,Total, 12.Uhlt '13.Waste Codes
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<br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol.
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<br /> 14 Special Handling Instructions and Additional Information v.Q
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<br /> 15, GENERATOR'SIOFFEROR'S.CERTIFICATION:•,Jrhereby,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 labeledlplaoarded,and areifn all respsoNs,in proper condition for transport according to.appiicable international and national governmental regdlations.If export shipment antll am the Primary
<br /> Exporter,1 certify that the contents of(I Is consjgnr'."t conform the terms of the attached EPAAcknowledgment of Consent
<br /> I certify that the waste minimization st!"'tmant id'entl in 40 CFR 262,27(a)(if I am a large quantlty.generator)or(b)(if I am a small quantity generator)Is true.
<br /> Generator sl�lfferoes Pr^l!oted/Typed Name Signature,) ; i^'"' Mog(h Day t Year
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<br /> FlExport from U.S. Port of entry lexitt:
<br /> � Interhational Shipments Import to U.S.
<br /> Transporter signature(for exports.only): Date leaving U.S
<br /> W 17.TransporterAcknowiedgmenI of Receipt of Materials w
<br /> Transporter 1 rfatedlTyped Nam Signature f' r, Mo$ Day ear
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<br /> 7anjp60er 2 Printedrryped Name.,, Signature Month Day Year
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<br /> 18.Discrepancy
<br /> 18a.Discrepancy Indication Space El Quantity ❑Type ❑Residue Or
<br /> Partial Rejection ❑Full Rejection
<br /> Manifest Reference Number:
<br /> 18b,Altemate Facility(or Generator) U.S.EPA ID Number
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<br /> ua. Facilllys Phone:.
<br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year
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<br /> 19,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems)
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<br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a
<br /> Signature Mont Day Year
<br /> Printed/Typed Name
<br /> EPA Form 8700-22(Rev,•3.05) Previous editions are obsolete. TRANSPORTER'S COPY
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