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` <br /> Please 00jit-ortype.Vorm desi ned for use on elite(12-pitch)typewdter.) Form Approved.OMB No. <br /> 039 <br /> Number 2.Pa �esponse Phone 4.Manifest Tracking Number <br /> UNIFORM HAZARDOUS P.GeneratorlD —? — <br /> Generators SiteAddress(if different than mailing address) <br /> Generators Phone: <br /> rterTGo <br /> U.S.EPA ID Number <br /> Facilit es Phone: <br /> 9a. 9b.U.S,DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 13.Waste Codes <br /> HM and Pecking Group(if any)) No. Type Quantity WtdVol. <br /> LU <br /> 3. <br /> 4. <br /> 14,Sp�a,I Handling Instructions and Additional Information <br /> 15, GENERATOR'$IOFFEROR'S CERTIFICATION: I hereby declare that the contents of this con6ignment 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 Internaflonal 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 certily that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generator's/Offe rinted[Typed ame signature, Month Day Year <br /> 15 k1p <br /> j 16.International Shipments El import to U.S. Ep,'on from U,S. Fort of entry/eAt: <br /> 2: Transporter signature(for exports only): Date leaving U.S.: <br /> LW 17.TransporterAcknowledgment of Receipt of Materials <br /> CA K e((e <br /> Transpqrter 2 Printedrryped Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity Full Rdj.cti.n <br /> Type M Residue El Partial Rejection F <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> FacillVs Phone: <br /> ont <br /> —7 <br /> LLj 18c.Signature of Alternate Facility(or Generator) h Day Year <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> Uj <br /> 20,Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PdntedfTyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> TRANSPORTER'S COPY <br /> ' / <br />