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Please print of type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved,OMB No.2054,0039
<br /> UNIFORM HAZARDOUS 1.GeneratorlD Number."; 2 P e 1 of 3.Emergency Respon$ePbone 4,Ma tife� Trac king N�rnbee
<br /> WASTE MANIFEST JJ
<br /> 5 Genera ors Name,'eRd Mailing Address Generatgr's Site,Address(rf,different than,mailing address)
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<br /> Generator's Phone:
<br /> 6.Transpc)terVCompan Naive " US EPAJDtJapibe r i;,
<br /> 7.Tr p 56r�C,o{npany Name"� t t- t M 1 U.S,EPS ID Number (.
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<br /> 8 Desi,!Pap F cilityNameandSfleAddress' U5.EPAIDrNumber .
<br /> Facility's Phone:
<br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class ID Number,,,, 10.Containers 11.Total 12,Unit 13.Waste Codes
<br /> HM and Packing Group(if anY))4t......,,... ,;...: Ne.. Type Quantity Wt.Nol.
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<br /> 14.i,SK afFlanUling Instructions and Additional Information'
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<br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I 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 labeled/placarded,and are in all respects in proper condition for transport according t0;applicabieIhtemational and national govemmental regulations.;if export shipment and I am the Primary'
<br /> Exporter,I certify that lhe'contentsof this consignment conform to the terms of ttie attached EPAAcknowledgment ofConsent.
<br /> I certify that the waste'minimiz,a n statement Identified In 40 CFR 2f2,21(a)(if I am a large quaht(ty generator)or(b)(if 1'am a small guaniity generator)Is true.
<br /> GeneratoeslOfferg"rinte pe Name ��` ;t Signature `.) r• Month aay ((Ydar
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<br /> j 16.International Shipments
<br /> E— ❑import to U.S. ❑Export from U,S,, F Port of entrylexit
<br /> Transporter signature(for exports only):,, ,'r, Date,legying U.S.:
<br /> w 17.Transporter kcknowledgment of Receipt of Materials
<br /> 12 Transporter 1 P[ eh 4�ed Nairfe ( Signatur Month EN Yeata
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<br /> QTransporter 2 P ri¢t`d(T.yped Name,,-* �,'j ,7 Z Signature "; N.; Mo Aa Y r
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<br /> 18.Discrepancy
<br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type
<br /> ❑Residue ❑Pariial.Rejection ❑Full Rejection
<br /> Manifest Reference Number.
<br /> 18b.Ntemate Facility(or Generator) U.S:EPA ID Number
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<br /> tea. Facilitys Phone: f�
<br /> W 18c,Signature of Alternate Facility(or Generator) Month Day Year
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<br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,'dlsposal,and recycling systems) '
<br /> 0 1. 2. 3. 4,:
<br /> 20.Designated Facility Owner or Operator:Certificatfon of receipt of hazardous materials covered by the manifest except as noted in Item 18a
<br /> Printed(iyped Name Signature Month Day Year
<br /> EPA Form 8700-22(Rev.3.05) Previous editions are obsolete. TRANSPORTER'S COPY
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