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• • Form Approved,OMB No.2050-0039 <br /> e print or type.(Form designed for use on We(12-piN11) writer.) - <br /> UNIFORMHAZARDOUS 1.Generator ID Number 2. Emergency Response Phone 4 Man reckl 19um er <br /> WASTE MANIFEST <br /> 5.Generators Name and Mailing Address Generebrs Site Address(dddferent than meiling address) <br /> Generators Phone: U.S.EPA ID Number <br /> 6.Transporter 1 Company Name <br /> U.S.EPA ID Numcer <br /> 7.Transporter 2 Company Name 4 <br /> B.Daslgnatetl <br /> US.EPA IO Number <br /> FadI11y Name and Site Address <br /> Fadliys Phone: <br /> 10.Containers 11.Tatal 12 Unit <br /> ga 9b.U.S.DOT Dascnp8on(nduding Proper Stopping Name,HazaN Class,ID Number, 13.Waste Cotler <br /> HM and Packing Group(if any)) No. Type Quantity WWoI. <br /> 17 7 <br /> O ' <br /> I <br /> w 2 <br /> so <br /> I <br /> IEEE <br /> 14.Special Handing Instructions and Additional Infomretion <br /> ,. <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately des l=ed above by the Proper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and nabonal governmental regulations.If export shipment and I am rile Primary <br /> Exporter,I cei that the contents of this consignment contort to the terms of the attached EPAAcknowledgment of Comal <br /> 1 certify Nat the wade minimization statement Identified in 40 CFR 26227(x)IN I am a large quantity generator)or(b)(if I am rima quantity generr ion)Is we. <br /> Signature / Monti Day Ycer <br /> GeneratorslORemrs _..YPed dame / �,/ q i 7 <br /> 16.International Shipments ❑Impart to U.S. ❑Export from LLS:% Port of entrylent <br /> Z Transporter signatu a(for exports only). Date leaving U.S.: <br /> 17.TransporterArkmuAedgment of Receipt of Matenals Signature it Monti DaY Year <br /> �7ronspater 1 PrintedRyped Name { _ <br /> a Y ,J 2 2 <br /> a Tmrwrror 2 Prinfed/iyped Name Signa��" Monty Day Year <br /> 6 <br /> C <br /> F <br /> 18.Discrepancy <br /> 18x.Discrepancy indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> v <br /> Manifest Reference Number. <br /> I 81d.Ammate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> tai Facility's Phone: <br /> w 18c.Signature of AHemate FaraTdy(or Generator) Month Day Year <br /> Q <br /> Z <br /> a—i 19.Hazardous Waste Report Management Method Codes(i.e..codes for hazallous waste treatment disposal,and recycling systems) <br /> 1. - I 2. <br /> 3. 4. <br /> 1 20 Designated Facility Ovmer or Operator.Cesdicabon of rete pt of hazardous materials wvaretl by tie manliest ex ep as aso in Item 18a <br /> 7(y"g <br /> n—PI dNarne t (r$!9 rek r—� t t t Monti Day Year <br /> Ili y/ <br /> EPA Form�8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />