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<br /> Please print or type. Form Approved , OMB No, 2050-0039
<br /> 1 . Generator ID Number TPage 1 of 3 Emer�q@�qy Respopse Phone 4 Manifest Tracking Number
<br /> UNIFORM HAZ/yRDOUS t ( ?(�ir dl t 3 ) .,s. ',.
<br /> WASTE MANIFESTSKS
<br /> 5. Generator's Name and Mailing Address Generators Site Address (if different than mailing address)
<br /> Generator's Phone:
<br /> 6 Tragsporter G1 Company 6 U .S. EPA ID Number
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<br /> 7. Transporter 2 Company Name U.S. EPA ID Number
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<br /> 8. Designated Facility Name and Site Addresst� ( ft ( � y ) )fit (r tt Ir U.S . EPA ID Number
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<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)) No. Type Quantity Wt.Nol.
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<br /> 14. Special Handling Instructions and Additional Information F Y e €
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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 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 certifythat the waste minimization statement identified in 40 CFR 262 .27 a if I am a large quantity generator) or if I am a small uanfit` enerator us true.
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<br /> Generatoes(Offeror's Printed/Typed Name Signature Month Day Year
<br /> J 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.:
<br /> ea! 17. Transporter Acknowledgment of Receipt of Materials
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<br /> Transporter "I Printed/Typed Name Signature . Month Day Year
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<br /> 2P Transporter 2 Pdntedl yped Name Signature Month Day Year
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<br /> 18. Discrepancy
<br /> 18a. Discrepancy Indication Space ty ❑ Type ❑ Residue ❑
<br /> Quantity T e Partial Rejection Full Rejection
<br /> Manifest Reference Number:
<br /> 18b, Alternate Facility (or Generator) U.S. EPA ID Number
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<br /> Facility's Phone:
<br /> Lo 18c. Signature of Alternate Facility (or Generator) 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 /> Prinled(ryped Name Signature Month Day Year
<br /> EPA Form 870Q-22 (Rev. 12 17) Previous editions are obsolete GENERATORS INITIAL COPY
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