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Please print or type. (Form designed for use on elite (12-pitch) typewriter) Form Approved , OMB No. 2050-0039 <br /> UNIFOW HAZARDOUS 1 . Generator ID Number 2, Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number �( <br /> WASTE MANIFEST SKS <br /> c V <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 /> 9a 9b, U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Total 12. Unit <br /> 13. Waste Codes <br /> HM and Packing Group (if any)) No. Type Quantity WUvol. <br /> 1 . <br /> O <br /> z 2, <br /> LU <br /> U) <br /> 3. <br /> 4. <br /> 14. Special Handling Instructions and Additional Information <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 EPA Acknowledgment 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/Offerors Printed/Typed Name Signature Month Day Year <br /> —J 116, International Shipments <br /> PmV ❑ Import to U.S. El Export from U.S. Port of entry/exit: <br /> Z Transporter signature (for exports only): Date leaving U.S.: <br /> W 17. TransporterAcknovdedgment of Receipt of Materials <br /> Transporter 1 Printedfryped Name Signature Month Day Year <br /> O <br /> CL <br /> QTransporter 2 PrintedfTyped Name Signature Month Day Year <br /> F- <br /> 18, Discrepancy <br /> 18a . Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number. <br /> 18b. Alternate Facility (or Generator) U.S. EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> W 18c. Signature of Alternate Facility (or Generator) Month Day Year <br /> Q <br /> Z <br /> as19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> LLI 1 2• 3, 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 /> Printedffyped Name Signature Month Day Year <br /> EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete . GENERATOR ' S IPII T IAL COPY <br />