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Please print or type. (Form designed for use on elite (12-pitch) typewriter.) Form Approved. OMB No. 2050-0039
<br /> UVIFORM HAZARDOUS : I . Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4 Manifest Tracking Number
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<br /> WASTE MANIFEST
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<br /> 1 5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) -
<br /> Generator's Phone:,-
<br /> 6. Transporter 1 Company Na'me:' U.S. EPA ID Number
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<br /> 7. Transporter 2 Company Name 4 U.S. EPA ID Number
<br /> 8. Designated Facility Name and Site Address U.S. EPA ID Number
<br /> Facility's Phone:ll
<br /> 9a. 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 WtNoi.
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<br /> 14, Special Handling Instructions and Additional Information
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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 classed, packaged,
<br /> marked and labeledtplacarded, 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 EPAAcknowledgment of Consent,
<br /> -j-:rjLcerfify that the waste minimization statement identified in 40 CFR 262.27(a) (d I am a large quantity generator) or (b) Sif i am a small quantity generator) is he.
<br /> Generaot's/0fferor's PnntedRyped Name Signature / ' -- Month Day Year
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<br />' 16. Inlematlonal Shipments
<br /> i- ❑ Import to U.S. ❑ Export from U.S, Port otentry/exit:
<br /> Z Transporter signature (for exports only): Date leaving U.S.:
<br /> 17. TransporterAcknowiedgmentofReceipt ofMaterials
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<br /> 0 Transporter 1 PrintedrTyped Name /i� Signature r l� �, Mon1�•r Day Year
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<br /> QTransporter Printed/Typed Name - - f Signature Month Day Year
<br /> 18, Discrepancy
<br /> 18a, Discrepancy Indication SpaceElQuantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Fuil Rejection
<br /> Manifest Reference Number.
<br /> 18b. Alternate Facility (or Generator) U.S. EPA ID Number
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<br /> LL; FaciliVs Phone:
<br /> w 18c. Signature ofAitemate Facility (or Generator) Month Day Year
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<br /> N19. Hazardous Waste Report Management Method Codes (t.e., codes for hazardous waste treatment, disposal, and recycling systems)
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<br /> 20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a
<br /> Printedlryped Name Signature Month Day Year
<br /> EPA Form 870042 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR STATE (IF REDUIRF117111
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