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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB <br /> No.2 <br /> UNIFORM'HAZARDOUS 1 GeQerator ID JJumber 2,Page 1 of 3 Emergency Response Phone 4 Manifest Tracking Number <br /> x .s <br /> WASTE MANIFEST <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> f.�jY iii" �x� <br /> Generator's Phone!:;: ,,-,.:�, <br /> 6.Transporter 1 Company Name U,S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address U.S.EPA ID Number. <br /> :T.. <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.N0I. <br /> t <br /> 0 ------ <br /> LU <br /> _ _LZ 2. I <br /> C9 ! <br /> 3. ) <br /> 4. <br /> f <br /> 14.Special Handling Instructions and Additional Information f t <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 dassiBed,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,l 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)(if I am a.smail quantity generator)is true. <br /> GeneratoeslOfferoes Printed/Typed Name Signature Month Day Year <br /> -J 16.International Shipments 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 /> UJ <br /> 1i Transporter 1 PrintedlTyped Name Signak+ra M Day Year <br /> ZZTransporter 2 PdntedfTyped Name Signature Month Day Year <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space El <br /> Quantity ❑Type El Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Facility's Phone: <br /> LU I8c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> LD <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> W 1. 2. 3. 4. <br /> i <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 188 <br /> Printed/Typed Name Signature r ._. Month Day Year <br /> t <br /> EPA Form 8700-22(Revl3-05) Previous editions are obsolete. DESIGNATED FACILITY'S Y'S COPY <br />