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Please print or type. Form Approved.OMB No.2050-41039 <br /> UNIFORM HAZARDOUS 1 Gene ator Ip Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tre-king Number <br /> WASTE MANIFEST J K <br /> S.Generatofs Name and Mailing Address Generators Site Address(if different than mailing address) �i�J I� <br /> Generators Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7 Transporter 2 Company Name <br /> U.S.EPA 1p Number <br /> 8.Designated Facility Name and Site Address U.S.EPA iD Number <br /> Fac9ilt Phone; ' <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12,Unit <br /> HM and Packing Group(8 any}) No. Type Quantity WtNol. 13.Waste Codes <br /> f. <br /> 4O <br /> w <br /> Z 2. <br /> W <br /> C7 <br /> 3. <br /> 4. <br /> 14.Special Handling Irstnrctions and Additional Information <br /> tb. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper.shrpping risme,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable intsmabonal and national gpvemmenlf6n <br /> tal reg0as.If export shipment and I am the Primary <br /> Exporter,t cer8ntorm <br /> ly that the contents of this consigrmant ooto the terms of the attached EPA Acknowledgment of Consent - <br /> 1 certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(If(amasiW' quantity gener4l0r)is hie. <br /> Generators=eroes Printedrryped Name Signature ` ✓ - ontlr Day Year <br /> _j 16.Interna 5 ipments <br /> a, <br /> ' 1:1 Import to U.S. ❑Export from U.S. Po�oyentrylexit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> OC W 17.Transporter Acknowledgment of Receipt of Materials <br /> O Transporter 1 PrintedfTyped Name Signature <br /> Month. Day Year <br /> CL <br /> ZTransporter 2 PrintedfTyped Name <br /> Signature Month Day Year <br /> t- <br /> 18.Discreperny <br /> 183.Disueoancy Indication Space El Quantity EIType <br /> ❑Resid;;e Portion Rejection ❑Fug Rejection <br /> Manifest Reference Number: <br /> 186.AEtemate Facility(a Generator} U.S.EPR ID Number <br /> t.3 <br /> LL Facility's Phone: <br /> Lu 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Ze <br /> w19.Hazardous Waste Report Management Method Codes(i e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G t. 2- 3. 4. <br /> t I t <br /> 20.Designated Facdity Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Pr ntedTyped Name Signature <br /> Month pay Year <br /> EPA Form 8700-22(Rev.12-17) Previous edi5ons are obsolete. <br /> DESIGNATED FACILITY TO CEPdETOP, <br />