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Please print or UNIFORM HAZARDOUS WASTE MANIFEST Generator's Name and 6. 7. for use on elite 2. Page 1 of 1 3. Emergency ga 9b. U.S. DOT Description (including Proper Shipping Hazard ClassID Number HM and Packing Group (if any)) Name, , , 3. Form maiLng U..S. EPAID Number 10. Containers 11. Total 12. Und No. Type Quantity Wt.Nol. OMB No. 2050-0039 15. GENERpTOR'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, 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 Pr maty Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. Month Day 1 certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity g111 enerator) or (b) (if I am a small quantity generator) is true. WIN IIII III ME 11 1 1 11 Generator's/Offerors Primed/Typed Name ❑ Export from U.S. Port of entrylexit. 16. International Shipments ❑ Import to U.S. Date leaving U.S.: 17. TransporterAcknowledgment of Receipt of Materials 18. Discrepancy 18a. Discrepancy Indication Space 18b. Alternate Facility (or Generator) Phone: ❑ Quantity ❑ Type ❑Residue 18c. Signature of Alternarc � u„,,.•, - osal, and recycling systems) ement Method Codes (i.e., codes for hazardous waste treatment, disp3 19. Hazardous Waste RManageport 2, the manifest except as naked In Item 18a Signature d Facility OwnCertification of receipt of hazardous materials covered y Designate Owner or Operator: I 20. EPA Form 5700-22 Rev. 3-05) Previous editions are obsolete. ❑Partial Rejecfwn U.S. EPAID 4. Year ❑Full Rejection Gfrhl�RaiflR'S IN1T1�