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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST J J K <br /> 5.Generator's Name and Melling 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 She Address U.S.EPA ID Nomber <br /> Ot hit t4N-0/htHL -PVN <br /> .'tAMl 14 I LAMS IJA S I k t f <br /> Facili 's Phone: <br /> 9a. 9b U.S.DOT Descripton(including Proper Shipping Name,Hazard Class,ID Number, 10 Containers 11.Total 12.Unit <br /> HM and Packing Group(it any)) No. Type Quantity Wt.Noi. 13.Woo Codes <br /> 1 <br /> Z 2. <br /> w <br /> c� <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> CMEFt13E14GYc0NIACi (;Hi M1*04f.(' 1-801}42.4-9300W!)L ttHM11,4,.i yrs,t <br /> 4"9,'ISF,inA!,tot►rdF f)1F=it! AVPG:i.IFFmATF PF'rrc()14A( t"-rr; 1)-r iivi rr)f"�'1Ahf'ft <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 shat 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 /> GeneratoeslOfferor's Printed/Typed Name Signature Month Day Year <br /> -J 16.International Shipments <br /> Z 1:1 Import to U.S. ElExportfrom U.S. Port of entrylexit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> IX 17.Transporter Acknovredgment of Receipt of Materials <br /> Ce <br /> Transporter 1 Pnnted/Typad Name Signature Month Day Year <br /> O <br /> CL <br /> Cn <br /> Q Transporter 2 Prnted/Typed Name Signature Month Day Year <br /> rY <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity El Type ❑Residue El Partial Rejection E]Full Rejection <br /> } Manifest Ret <br /> F- 18b.Alternate Facility(or Generator) htUJk0SrVDWfflb1r <br /> J <br /> V <br /> L:C Facility's Phone <br /> LU 18c Signature of Alternate Facility(or Generator) MonthDay Year <br /> a <br /> z <br /> N EM, RE)NMENTAI= <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> o 1 2. 3. , <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PdntediTyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />