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� i Please print or type.(Formn desi ed for use on elite(12-pitch)bypewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS ener or u 'o-405 Jark 5.Generator's Name and Mailin Address Generator's Sile Address(if different than mailing address) Generators Phone: 6.Transporter 1 Company,Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number Facility's Phone: ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 2. LU 3. 14.Special Handling Instructions and Additional Information 15. GENERATOR'SIOFFEROWS 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, 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 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknovwedgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. [Genera—t,es/Offeror's Printed/Typed Name Signature Month Day Year -1 1 16.International Shipments I— El import to U.S. El Export from U.S. Port of entry/exit: 9 Transporter signature(for exports only): Date leaving U.S.: 11X 17.Transporter Acknowledgment of Receipt of Materials tE Transporter 1 Piripted/Typed Name ;7 Signature Month Day Year CL Z Transporter 2 Printedrryped Name Signature Month Day Year I18.Discrepancy 18a.Discrepancy Indication Space 0 Quantity El Type El Residue El Partial Rejection El Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number LL- Facility's Phone: uj 18c.Signature of Alternate Facility(or Generator) nth Day Year 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 120.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrintedfTyped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. i GENERATOR'S '--INITIAL COPY | |