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<br />Form Approved. OMB No. 2050-0039
<br />EPaFOIrItnV,00.22 (Re.'v. 3-05) Previous edjfibns are obsolete. 4 1 GENERATOR'S INITIAL COPY
<br />UNIFORM HAZARDOUS
<br />1. Generator ID Number i..'44,11 r ' 110',1 0 ';'_
<br />2. Page 1 of
<br />3. Emergency Response Phone
<br />4. Manifest Tracking Number
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<br />WASTE MANIFEST
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<br />5 Ge eratgrsNa and alin Address Gengr�}orsS,ieAd re s if,'�ggetentthan ailin address
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<br />Generator's Phone:
<br />tr-TMnspoitet 1 Coinda0y`Name i = t;.. t .; , , t: ,,; U.S. EPA ID Number
<br />7. Transporter 2 Company Name U.S. EPA ID Number
<br />8. Designated Facility Name and Site Address U.S. EPA ID Number
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<br />Facility's Phone:
<br />9a.
<br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number,
<br />10, Containers
<br />11. Total
<br />12. Unit
<br />13. Waste Codes
<br />No.
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<br />and Packing Group (if any))
<br />Quantity
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<br />15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the prober 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 arp a large quantity generator) or (b) (if I am a small quantity generator) is true.
<br />Generator's/Offerors Printed/Typed Name Signature Month Day Year
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<br />16. International Shipments
<br />❑ Import to U.S. ❑ Export from U.S. Port of entry/exit:
<br />Transporter signature (for exports only): Date leaving U.S.:
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<br />17. Transporter Acknowledgment of Receipt of Materials
<br />Month
<br />rans Transporter 1 PrintedffyPed Name Year
<br />DayTSignature
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<br />y`pede �' r Signature - " " Month Dayl Year
<br />Transporter2 Print�famA ._.- . /
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<br />18. Discrepancy
<br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑Partial Rejection Full Rejection
<br />Manifest Reference Number:
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<br />18b, Alternate Facility (or Generator) U.S. EPA ID Number
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<br />Facility's Phone:
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<br />18c. Signature of Alternate Facility (or Generator)
<br />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 />Printed/Typed Name Signature Month Day Year
<br />EPaFOIrItnV,00.22 (Re.'v. 3-05) Previous edjfibns are obsolete. 4 1 GENERATOR'S INITIAL COPY
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