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i <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter) Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS I.Generator ID Number 2.Page 1 of 3 Emergency Response Phone 9 Manifest Tracking Number <br /> I WASTE MANIFESTSKS <br /> is a �'•.:. E.T <br /> 5,Generators Name and Mailing Address 'Generators Site Address(if different than mailing address} , <br /> ,T` <br /> Generators Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7•Transporter 2 Company Name U.S.EPA ID Number <br /> .1.7<<" <br /> B.Designated Facility Name and Site Address U.S.EPA ID Number <br /> 71 <br /> Faclllly'sPhone: <br /> ga. 9b.US.DOT Description(including Proper Shipping Name,Hazard Cfass,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No Type Quantify WL/Vol. 13.Waste Codes <br /> 1 <br /> 1 [: <br /> ua <br /> Z 2. <br /> UA <br /> 0 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 15. G F3EItA7QR'S70 FE UR'5 C FtTIFICAT10N:'I Hereby declare that Ihebanlenls of Ifiis consig ment are°fully and a ccutately'descri$e above by I e proper"shipping name,and are classified,packaged, <br /> marked and labeledlpfacarded,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 10 the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization slalement 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 /> Generator'slOffenors Printedffyped Name Signature Month Day Year <br /> 16.International Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of entrylexit: <br /> ® Transporter signature(for exports only): 'Dale leaving U.S.: <br /> ra.l <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printedffyped Name Signature: Month Day Year <br /> B Transporter 2 PrintedlTyped Name Signature Month Day Year <br /> r <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection <br /> yp f F]Full Rejection <br /> Manifest Reference Number <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> 0 <br /> L<L Facility's Phone: <br /> LU 18c.Signalure ofAlternale Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 4. <br /> 20.Designated Fac€lily Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in item 18a <br /> PrinledfTyped Name Signature Month Day Year <br /> EPA Farm 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR INITIAL COPY <br />