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Please print or type. Form Approved.OMB No.2050-0039 <br /> Generator 10 Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> UNIFORM HAZARDOUS <br /> WASTE MANIFEST <br /> FLE <br /> 5.Generator's Name and Mailln Generator's Site Address(if different than <br /> _g Address mailing address) <br /> Generator's Phone: <br /> 6.Transporler I Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S,EPA 10 Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> -1 �z <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 VVLIVOI. <br /> 0 <br /> Y_ 2 <br /> 2. <br /> LLI <br /> 0 <br /> 3. <br /> 4, <br /> 14,Special_Handliqg Instructions and Additional Information <br /> 15. GENERATOR'SIOFFEROWS 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 10 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)(ifl am a small quantity generator)is true. <br /> Generator'slOfferor's Printed(Typed Name Signature Month Day Year <br /> L <br /> _j 16.International ShIpmerts; <br /> DImport to U.S. ❑Export from U.S. Port of entrylexit: <br /> Transporter signature(for exports only): Date leaving U.S,: <br /> W 17,TransporterAcicnowledgment of Receipt of Materfal5 <br /> LLJ <br /> I'— Transporter I Printed/Typed Name Signature Month Day Year <br /> C) <br /> D <br /> z Transporter 2 Printedriryped Name Signature, <br /> Month Day Year <br /> rr <br /> 18,Discrepancy <br /> 18a.Discrepancy Indication Space Quantity ❑Type 1:1 Residue El Prb.l Rejection ❑Full Rejection <br /> Manifest Reference Number- <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> LFacility's Phone: <br /> L <br /> 0 <br /> LLj 18c.Signature ofAltemale 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 /> LU 1 2. 4. <br /> C3 <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 87QO�22.(Rev. 7),,Previous.editons are-obscilete, <br /> R <br /> -Q.�K�RATP 'S)NMAL COPY <br />