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Please print or,type (Form designed for use on elite(12 pitch)typewriter.) "Ir' Form Approved,OMB No 2060 0039
<br /> UNIFORM HAZARDOUS 1.G�onn'eratoffr ID Number 2.Page 1 of 3 Emer,ency Response Phone 4,Mages Trpkln Nufnjtefr
<br /> WASTE MANIFEST
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<br /> 5.Generator's Name and Mailing Address ( Qeneraloesite Address(If different than mailing address)
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<br /> eneratoePhone: U.S;EPA)D }r bar
<br /> 6.Tr sporter•1 Com an Name's'
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<br /> 7. ransporter.2 Cpany Name �, US.EPA ID Number
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<br /> B,DeSigiibfed.Rabllityfttarri6)f�rs91t3,Address U.S EPA IDiNumber.!t r.
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<br /> Facility's Phone`..",
<br /> 1.0„Go tainers ,.
<br /> ga 9b.U.S.DOT Description.(includIng. roper Shipping Name,.Hazard Cless,,IDNumber, - 9 ;,r111.Total 92;Unit 13:Waste Codes
<br /> HM and Packing Group(if any)) No. Type Quantity. Wt.Nol.
<br /> r ,i�,,';,`4 it t Y r,J .�'. „ �,yr• {,L� t t{ $r-,irshrLt}lF�,t,i,£I ..p r' :,:,. �.,. C.
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<br /> 14:S�ele4� a �tl(rglnstructl6ris,andAddlt1onol•tnformsgon:
<br /> 15. GENERATOR'S(OFFEROR'S CERTIFICATION: 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 labeledlplaoard'ed,an`d are In ail respects in proper conditlon'for transport according to applicable International and national governmental regulations,if export shipment and I am the Primary
<br /> Exporter I cetllty that the contents of tljis consignment conform to the forms of the attached EPAAcknowledgment of Consent,
<br /> ('certify thalitie Wasle;m(nimhzafIons tatement Id6nllfletl In 40 CFR 261.7(a)(If I am a large quantity.genomtor)or(b)(if I am a small quantity generator)is true.
<br /> General6eslOffer`ors Prihted/ryped Nam Signature Month Day fyYear
<br /> _ 16.Intemal oval Shipments Import to U.S. ❑Export from U.S,,'? Port of entrylexit:
<br /> F= Transporter signature(for exports only): Date leaving U.S.:
<br /> w 17.TransporterAckn6'W6dgment'of Receipt of Materials
<br /> jE2 Transporter1Printe ype Name jfj Signature r' '' '' /� �;.+� Mo Day. Year
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<br /> � Month Day Year
<br /> Q Tr(a`nsporteor"r 2 Printed(lryped Name Signature /JJ/ p
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<br /> 18.Discrepancy
<br /> s 18a,Discrepancy Indication Space Q quantity ❑Type El Residue ❑Partial Rejection ❑Full Rejection.
<br /> Manifest Reference Number:
<br /> 185.AitemateFacility(or Generator) U.S.EPA ID Number
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<br /> ua. Facility's Phone-
<br /> UJ teoa 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 matedais covered by the manifest except as noted In Item 18a
<br /> Printed/Typed Name Signature Month Day Year
<br /> EPA Form 8700'22;(RbV,3 O6) Previous editions are obsolete. 7RAiVSPORTER'S COPY
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