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Please print or type. Form Approved. OMB No. 2050.0039 <br /> UNIFORM HAZARDOUSI, Generator ID Number 2. Page 1 of 3 Emergency Response Phone 4. Manifest Tracking Number <br /> v <br /> WASTE MANIFEST r f . . J J <br /> P . ,,, <br /> 5. Generators Name and Mailing Address Generator's Site Address (If different than malting address) <br /> r� r , <br /> Generator's Phone: <br /> 6. Transp1oder\1, Compa� y„N?( U.S EPRIQNPmber ; • ; <br /> 7. Transporter 2 Company Name U.S. EPA ID Number <br /> 8, Designated Facility Name and Site Address`- - U.S. EPAID Number <br /> Facility's Phone: <br /> ga. 91b. 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)) <br /> No. Type Quantity Wt.Nol. <br /> 1 . „ si .'. , , wt _ y _ � !. It <br /> Z 2. <br /> W <br /> 3. <br /> 4 . <br /> 14. Special �igndiing Instructions and Additional Information <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 EPAAcknowiedgment 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) (III am a,small quantity generator) is true. <br /> GeneratorslOfferoes Printed/Typed Name Signature _ , Month Day Year <br /> 16, International Shipments <br /> H ❑ import to U.S. ❑ Export from U.S. ' Port of entry/exit: <br /> z Transporter signature (for exports only): Date leaving U.S.: <br /> ce 17. Transporter Acknowledgment of Receipt of Materials <br /> � Transporter i .Printe yped Name Signature r” Month Day Year <br /> 1 , / . <br /> 1 r <br /> zTransporter 2 Printed/Typed Name Signature Month Day Year <br /> F- <br /> 18, Discrepancy L+t= <br /> 18a. Discrepancy Indication Space ❑ Quantity ElType Residue ❑ Partial Rejection ❑ Full Rejection <br /> ❑ <br /> Manifest Reference Number: <br /> 18b. Alternate Facility (or Generator) U.S. EPA ID Number <br /> V <br /> W Facility's Phone: <br /> W 18c. Signature of Alternate Facility (or Generator) Month Day Year <br /> Q <br /> N19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> 0 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 /> Printed/Typed Name Signature Month Day year <br /> EPA Form 8700-22 (Rev. 12- 17) Previous editions are obsolete . GENERATOR ' S INITIAL. COpY <br />