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Please print or type. (Form designed for use on elite (12-pitch) typewriter.) Form Approved. OMB No. 2050-0039
<br /> UNIFORM HAZAR7 ,:Generalor IDN bar 2. Page 1 of 3. Emergency Respon e Phone 4. Manifest Tracking Number
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<br /> WASTE MANIFCST C J 7 fj/ r '[ cd} 1 f 00 Q 2" y, 1 m i DAT
<br /> 5. Generators Name and Mailing Address 4E t , Ic O, ir/ Fi0tc-t GeneratorsSiteAddress different(if than mailing address)
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<br /> Generators Phone:
<br /> 6. Transporter 1 Company Name U.S. EPA ID Number
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<br /> 7. Transporter 2 Company Name U.S. EPA ID Number
<br /> 8. Des gn ted Facility Name and Site Address U.S. EPA ID Number
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<br /> Facililys 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 WINol.
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<br /> 14. Special Handling Instructions and Additional Information F,7 -p(3� ;q j �2ui -d ,(
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<br /> 15. GENERATOR'SIOFFEROWS CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the propershipping 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) (ifI am a small quantity generator) is true.
<br /> Generalues/Offerors Prinfedffyped Name Signature Month Day Year
<br /> J 16. International Shipments
<br /> i— ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit:
<br /> Transporter signature (for exports only): Date leaving U.S.:
<br /> 17. Transporter Acknowledgment of Receipt of Materials
<br /> Transporter 1 PrintedName..,Name -- Signature , - J' Month Day Year
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<br /> Z Transporter 2 Prinled(ryped Name Signature - Month Day Year
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<br /> 18, Discrepancy
<br /> 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection
<br /> Manifest Reference Number:
<br /> r 18 b. Alternate Facility (or Generator) U.S. EPA ID Number
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<br /> <Q Facithr's Phone:
<br /> w 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 /> I,� 20. Designated Facility Owneror Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a
<br /> Prinledif yped Name Signature Month Day Year
<br /> °A Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR' S INITIAL COPY
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