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1 <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 777 <br /> 3.Emergency Response Phone 4.Manifest Tracking Number (��[cWASTE MANIFEST <br /> UNIFORM HAZARDOUS 1,Generator ID Number V IRV <br /> 5-Generator's Name and Mailing Address Generators Site Address(if different than mailing address) .4389 <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 1D 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)) Na, type Quantity Wt.Noi. <br /> jX <br /> 1. <br /> O7y . . ' <br /> I1J <br /> 2 2. <br /> 3. P, <br /> 4. <br /> i <br /> 14-Special Handling Instructions and Additional Information <br /> wc}Twi:C:� <br /> •i - .V1 ii �1" .T' -.l if• 3r 5+ .� .'u}' it ']'. <br /> 15. GEN ERATOR'SlOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classifiti <br /> ed,packaged, <br /> marked and labeledlplacarded,and aro in all respects in proper condition for transport according to applicable international and national governmental regulations.It 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 /> Generatod siOfferoes Printed/Typed Name Signature Month Day Year <br /> 16.Internalional Shipments f <br /> F ❑Import to U.S. ❑Export from U.S.' Port of entrylexit: _ <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> W17.Transporter Acknowledgment of Receipt of Materials <br /> Transpag6r 1 P,intedlTyped Name Signature Month Day Year <br /> a Transporter 2 PrintedlTyped Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space QuantityType❑ yp ❑Residue ❑Partial Rejection ❑Fall Rejection <br /> Manifest Reference Number: <br /> H 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> Facility's Phone: <br /> Lu 1.8c.Signature of Alternate 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 /> 0 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 183 <br /> Pdnfedffyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL.COPY <br />