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�z <br /> Please print or type. Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 7,wr 1D Number 2.Page 1 of 3.Emergency Response Phone 4,Manifest Tracking Number <br /> WASTE MANIFEST F L E <br /> v y <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Generalor's Phone: <br /> 6,Transporter 1 Company Name <br /> 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 /> oa 9b.U.S.DOT Description(including Proper Shipping Name.Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HIM and Packing Group(if airy)) 13.Waste Codes <br /> No. Type Quantity Wt IVoI- <br /> 1- <br /> o I_ <br /> r- <br /> a - <br /> ru <br /> UJ <br /> 2. <br /> c� <br /> s. <br /> 4- <br /> 14.Special Handling InsIbuctions and Additional Information <br /> f <br /> 15. GEN ERATOR'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 labeiedlplacarded,and are in all respects in proper condition far transport according to applicable intemational and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consiigament 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 genvraVa is true. <br /> Generator'slOfferors PrintedlTyped Name Signature Month Day Year <br /> 16.Internalional Shipments <br /> F- ❑Import to U-S. ❑Export from U.S- Port of entrylexit: <br /> 9 Transporter signature(far exports only): Date leaving U.S-: <br /> W 17.Transporter Acknowledgment of Remipt of Materials <br /> Transporter 1 Printed,Typed Name Signature Month Day Year <br /> d _ <br /> Transporter 2 Printed.-Typed Name Signature Month Day libw'' <br /> H <br /> 1 S.Discrepancy <br /> 18a-Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> F 18b.AREemate Facility(or Generator) U-S-EPA ID Number <br /> J_ <br /> C] <br /> t4i Facility's Phone- <br /> maim18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> a <br /> 19.Hazardous Waste Report Management Method Codes(i-e-,codes for hazardous waste treatment:disposal,and recycling systems) <br /> LU p 1• 2. 3. 4. <br /> 20.Designated Facility(]wirer or Operator:Certification of receipt Df hazardous materials covered by the manifest except as nded in Item 18a <br /> PrmtedfTyped Name Sicdnature Month Da'+ Year <br /> EPA Form 8700.22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />