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Please print or type.(Form 00%ch)typewriter.) ) f a <br /> 1.Generator ID Number Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 2.Page 1 of 3.Emergency Response PhonZ <br /> 4.Manifest Tracking Number <br /> WASTE <br /> MANIFEST FLE <br /> 5.Generator's Name and MaBing A <br /> Generators Siteftercr ailing V_.; <br /> + mmx; a, <br /> ISVo-: <br /> P800 <br /> 6.Transpoder 1 Com •:s <br /> a -ti <br /> U.S.EPA ID Number ., <br /> 7.Transporter2 Company Name <br /> U.S.EPA ID Number <br /> 8.Designated Facility Name Address -U.S. <br /> and Site <br /> EPA ID Number <br /> five U <br /> ga, 9b.U.S.DOT ascription(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers <br /> P <br /> and Packing Group(if any)) 11.Total 12 Unit 13.Waste Codes <br /> No. Type Quanpty WtNol . <br /> . <br /> LU <br /> LU <br /> 4. <br /> - r _ <br /> 14.Special Handling Instructions and Additional Information <br /> .. i <br /> ter. .;+'w ^T <br /> 15. GENERATOR SlOFFEROR S CERTIFICATION: I hereby declare that the contents of this consignment are mi y and accurately described above by fheproper s'pp ng name,and are r0assified,pa g;'1 <br /> marked and labeled/piacarded and are in all respect.s 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 that the contents of this consignment conform to the terms of the attached EPAAcknowledgment 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 <br /> oneratoes/Offeror's Pnnte yped Name q ty genera is true <br /> igna re <br /> Month Day ear <br /> 16.Int mat nal Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port ofthe ry/exit <br /> Z Trans orter s'nature for exports only): <br /> IX 17.Transporter Acknowledgment of Receipt of Materials Date leavin U.S.: <br /> w <br /> Transporter 1 Pnntedfryped Name <br /> Signature <br /> ay ear <br /> transporter 2 Printed/Typed Name ignature \ <br /> Mon. ay <br /> year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity <br /> Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> 18b.Alternate Facility(or Generator) Manifest Reference Number. <br /> U.S.EPA ID Number <br /> V <br /> Q <br /> r+- Facilit's Phone: <br /> F18Alternate Facility(or Generator) <br /> c.Signature of A <br /> zMonth Day Year <br /> LU 18.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1 2• 3. 4. <br /> —7— <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> fttedfryped Name Signature <br /> Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> OENCR ATOWS HNiTi<At_COPY <br />