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Form Approved, OMB No. 2050-0039
<br /> US ,1 . Generator ID Number 2. Page 1 of 3. Emergency Response, Phone 4. Man st rj in Number
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<br /> ;me ar d DAailingAddress _ _ . ; ' _ Generator's Site Address (if different than mailing address)
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<br /> Bator's Phone:
<br /> ;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 /> B. Designated Facility Name and Site Address U.S. EPA ID Number
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<br /> ga. ' 9b. US: DOT Description (including Proper Shipping Name, Hazard Glass, ID Number,' 10. Containers 11 . Tole 12. Unit 13. Waste Codes
<br /> 4 HM and Packing ,Group CifanY)) No. Type Quantity WLNol:
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<br /> 14. Special Handling Instructions and Additional Information :; i
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<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, and are classified, packaged .
<br /> markedand labeled/placarded, and are In all respects In proper condition for transpo��jeJaccording to applicable International and national governmental regulations if export shipment and jambe Primary
<br /> Exporter, I III I certify that the contents of this consignmenPconform to the terms 8f the attacfied EPAAcknowtedgment of Consent.
<br /> t certify that the waste minimization statement identified tri d0 CFR 26227(x) (if i aln'a large quantity generator) dr (b) rfl am a small quantity geneiafor) Is true. ,
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<br /> Generators/Offe r Pnnled(fy ed Name Signature; - Month Day (ear:
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<br /> 16. Intemati nal " ipme is
<br /> L ❑ Import to U:S: � Export from U.S. Port of entrylexit� „
<br /> Transporter signature (for exports only): " ' Date leaving U,S;, , I r, rLI 41 Ellie
<br /> -17. Transporter AcknoWedgment of Receipt of MatedalsLI
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<br /> Transporter 1 Printed/Typed Name Signs Y
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<br /> ransporter2 rinted/TypedName Signature Month Day ear
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<br /> 18. Discrepancy
<br /> 18a. Discrepancy Indication Space rFull Re ection
<br /> ❑ Quantity EJ Type LJ Residue . , ❑ Partial Rejection : t
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<br /> 18b. Alternate Facility (or Generator) U.S. EPA ID NumberLd
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<br /> Facility's Phone:
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<br /> 18c. Signature of Alternate Facility (or Generator) . Month Day Year
<br /> 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) >
<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
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