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Please print or type.(Form designed for use on elite(12-pitch) r) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2 Page 1 of 3. lency Response Phone 4.Man Tracking Number <br /> WASTE MANIFEST f # 68 �� <br /> 5.Generators Name and MahThng Address Generators Site Address(d different then ming address) <br /> Generators Phone: <br /> 6.Transporter 1 Cofripany Name r U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address r e 1 U.S.EPA ID Number <br /> sic ( )#�•�:, <br /> CADOM <br /> B"4 <br /> Faalil(s Phone: <br /> W. 9b.U.S.DOT Description(hnduding Proper Shipping Name,Hazard pass,ID Number, 10.Containers 11.Total 12.Unit <br /> 1' <br /> HM and Packing Group(d any)) No. Type <br /> Quantity WL/Vol. 13.Waste Codes <br /> tY <br /> Z 2. ; <br /> w <br /> t9 <br /> 3. <br /> 4. <br /> 14.$pedal Handling Instructions and Add clonal Nfomrston <br /> 15. GENERATOR'S/OFFEIMS CERTIFICATION: I hereby declare that the corhtents of this consignmherd are fully and above by the proper shipping name,and are classified,packaged. <br /> marked and labefediplacarded,and are in all respells in primer condition for transport according to international and national governmental regulations.t 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 mend of Consent. <br /> I certify that the waste mmuni abon statement identified'm 40 CFR 262.27(a)(d 1 am a large quantity generator)or(b)(d I am a small <br /> quantity generator)istnre. <br /> Generators/Offeroes.PdnWffyped Name Signature Month Day Year <br /> -j 16.International <br /> Shipments <br /> I— ❑Import to U.S. ❑Export from U.S. Port of entry/exit <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.TransporterAdmowledgment of Receipt of Materials <br /> O Transporter 1 PrinteWTyped Name Signature <br /> Month Day Year <br /> Transporter 2 Signature Month Day Year <br /> h <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Typs ❑Residue ❑Partial Rejection ❑Full Rejection <br /> 18b.Alternate Facility(a Manifest Reference Number.Generator) U.S.EPA ID Number <br /> J <br /> Ca <br /> Facility's Phone: <br /> 18c.Signature of Alternate Facfifty(or Generator) <br /> Month Day Year- <br /> 19. <br /> ea19.Hazardous Waste Report Management Method Codes(i.e.,caths for hazardous waste treatment,disposal,and recycling systems) <br /> � 1. 2• 3. 4, <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printedtfyped Name Signature Mpnth pay Year <br /> 05 Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />