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Please print or type. Form Approved.OMB No.2050-0039 <br /> at nihfest Terack n <br /> g Number <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2.Page 1 of 3.Emergency Response Phony 14.M <br /> WASTE MANIFEST , <br /> w d , <br /> JJ <br /> 5.Generator's Name and Mailing Address a Generator's Site Address(d different than mailing address) <br /> S<'d IC.r t ����3 <br /> A <br /> Geneat is Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7. �r E <br /> , r r • � .: . r' f 1 <br /> Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address3°t / U.S.EPA ID Number <br /> t'?d, t 1 ✓ <br /> Facili s,Phono:' <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> 13.Waste Codes <br /> HM <br /> and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> 1 ,7 <br /> Rr <br /> O <br /> 2 2. <br /> LU <br /> 0 <br /> f� <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> fu <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 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 terms of the attached EPA Acknowledgment of Consent. <br /> I certify 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/Offeror's Printed/Typed Name Signature Month Day Year <br /> 116.International Shipments <br /> t'— ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> � Transporter signature(for exports only): Date leaving U.S <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Uj <br /> 12 Transporter 1 Printed/typed Name Signature Month Day Year <br /> IL s <br /> Transporter 2'Pnnted/Typed Name / Signature Month Day Year <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity ❑Type ❑Residuej j <br /> ❑Partial Rejection Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> B <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> Uj 1. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed(ryped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />