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i <br /> r <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No ' <br /> UNIFORM HAZARDOUS `1.Generator ID Number2.Page 1 of 3 Emergency Response Phone 4.Manifest Tracking Number <br /> ry <br /> WASTE MANIFEST <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mauling address) <br /> ?"Ji 2,n <br /> : <br /> Generators Phone'-'" <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> F,0fqtVAL. <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address-, U.S.EPA ID Number <br /> —Sri SAL <br /> Facility's Phone'tts"'a'2< i7 <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./Vol. <br /> 1. <br /> d' <br /> 0 <br /> WfJ I <br /> 3 <br /> I t <br /> 1 <br /> 4. <br /> i <br /> f <br /> 14 Special Handling Instructions andA)jd#i ionat nfrmation <br /> S.WWI <br /> bT--'TKklmeo Ll F11 <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,.ard 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 1 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 certifysthat 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. <br /> Generatoes/Offeroes Printed/Typed Name Signature Month Day Year- <br /> f <br /> 91 <br /> 16.International Shipments <br /> Z <br /> ❑Import to U.S. El Export from U.S. Port of entry/exit: <br /> Transporter signature(for exports only): Data leaving U.S.: <br /> W 17.TransporterAcknowledgment of Receipt of Materials M <br /> Transporter 1 Printedrr, ed Name ', ( Signature Month Day Year <br /> CL <br /> Transporter 2 Printed/Typed Name Signatures' Month Day Year <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity Type El Partial Rejection ❑Full Rejection <br /> ection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> V <br /> Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> ca <br /> G 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 /> Printedrryped Name SignatureMonth Day Year <br /> i <br /> EPA Form 8700-22(Rev.P-05) Previous editions are obsolete. DESIGNATED FACILITY'S COPY ., <br /> N� <br /> t <br />