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Please p:mt ci 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 7anifest Tracking Number <br /> F G <br /> WASTE MANIFEST O,j a %� ! 98 GBF <br /> 5.Generators Name and Mailing Address Generator's Site Address{if different than maliN address) <br /> Generators Phone: <br /> 6.Transposer 1 Company Name U.S.EPA ID Number <br /> 7 Transporter 2 Company Name U.S EPA ID Number <br /> 8.Designated Facility Name gnd Site Address U.S.EPA iD Number <br /> Facility's Phone: <br /> 9a 9b.U.B.DOT Description(including Pm[)er Shipping Name,Hazard Class.ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No, Type Quantity Wt.Nol. 13•Wast®Godes <br /> w <br /> L 2. <br /> w <br /> C7 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Informalion <br /> 15. GENERATOR'WOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are dassifled,packaged, <br /> marked and labelediplacarded,and are in all respects in propercondibon for transport according to applicable inlematonai and national governmental regulations,If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment cartoon to the tenors of the attached EPA Acknowledgment of Garment. <br /> J certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantty generator)or(b)(if)am a small quantity generator)is true <br /> Gene ralorsi0fpercrs Pnn*cUTyped Name Signature Ml Day Years <br /> 16.Intemational Shipments <br /> F- ❑import to IIS. ❑Export from U.S. Pert of entrylexit: <br /> Transporter signature(for exports only): Date leaving U.S_: <br /> w17.TransporterAdmowtedgment of Raceipt of Materials <br /> Transp&W 1 Prin*Vyped'Name SighAturs- Month Dav Year., <br /> ------------- <br /> Transporter 2 PrintedlTyped Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy indicarinn Space ❑ quantity ❑Type ❑Residue ❑Partial Rejection ❑Rfl Rejection <br /> Manifest Reference Number: <br /> 18b.Atfemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> U.1 18c.Signature of Alrernate 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 /> 2 3 T- <br /> 20 <br /> Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 16a <br /> Prntedlfyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsdete. <br /> GENERATOR'S INITIAL COPY <br />