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Plea�`i7rint or tvoe. (Form desioned for use on elite (12 -Ditch) tvoewriter.) <br />Form Approved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. °-. ,°ta4�t"�4 Ip :, I,„('( -V -"11-; tar <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />WASTE MANIFEST _ <br />I <br />J J K <br />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 Name U.S. EPA ID Number <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 />Facility's Phone: <br />ga <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12, Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any.)) <br />Quantity <br />Wt.Nol. <br />1. <br />tr <br />O <br />w <br />O <br />3., -1/A`, � )`: ht. €1;P i� 1-i :;I.Jt If.t`.�, (0R(i( 4,(.i; ? <br />N F 4 .:1 K. P! ; I Vit: �. f'> <br />4. <br />14. Special Handling Instructions and Additional Information <br />„. <br />6 (. <br />:��::.,�-.�.. �>'.��k3�° �t � ;� l �, f✓ �� z k) f : 5 A i> 4 3 '; p_,44 4 <br />(� <br />�e,F+E.,;Xy +tit GI..F ` F., PR01Ef i JV C1.0i i1N 0 t•; <br />'t z .. •-"-w t�i 23� "�„�y:. �,.. <br />f (� `I r i <br />f: lik . �Ili t I -'?""` ` h;" r ,' 4"> ? (, , 1 Y"° j ' ? . <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 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 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 />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 small quantity generator) is true. <br />Generator's/Offeror's Printed/Typed Name Signature Month Day Year <br />.J <br />f - <br />16. International Shipments <br />❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: _ <br />Z <br />Transporter signature (for exports only): Date leaving U.S.: <br />w <br />17. Transporter Acknowledgment of Receipt of Materials, <br />Transporter f Printed(fype,d Name Signature Month Day Year <br />Z�C <br />Transporter 2 Printed/Typed Name Signature Month Day Year <br />j <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Typej j <br />❑ Residue Partial Rejection Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />V <br />Facility's Phone: <br />w <br />18c. Signature of Alternate Facility (or Generator) ��� Month Day Year <br />Q <br />Z <br />N19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />A <br />1. <br />2. <br />3. <br />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 />Printed/Typed Name SignatureMonth Day Year <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. °-. ,°ta4�t"�4 Ip :, I,„('( -V -"11-; tar <br />