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• <br /> 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 Respogse Phone _ dSt1�3ckinN be <br /> WASTE MANIFEST 1- a ref:"' "�.. FLE <br /> 5 Generator's Name and Mailing Address Y k. '' ; Generator's pta Addrajss�(ifdifferent than mailing address) <br /> Generator's Phone <br /> 6Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number. <br /> 8. natedFacility Namea <br /> SdsAddfeas s'' r' U.S,EPA IDNumber <br /> �.. ...... <br /> a:, S k C..: w.w <br /> Facility's Phone. :-..:..: <br /> 9b.U.S.DOT Description(Including S' m Name,Hazard Class,ID Number,`. 10.Containers <br /> 9a. P C n9 Proper �P 9 � 11 Total . 12 Unit <br /> HM and Packing Group(f any)) J,iJo. TYPa` . ';'Quantity,;.: WtlVoi,? 13.Waste Codes <br /> . .: } t x �. 0..3 L'. ..ri- a-,. fid„. �•y : ,.,.�1 _�..-_ <br /> Z 2. <br /> LU <br /> 3. <br /> 4. <br /> 14.Special,Harbling Instructions and Additional Information <br /> 15. GENERATOR'SIOFFEROR'S CEITi F I=ON: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 labelediplacarded,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 that the contents of this consignment conform to the temps of the attached EPAAcknowledgment of Consent, <br /> Ice*that waste minimization statement identified in 40 CFR 262.27(a)(d I am a large quantity generator)or(b)Of <br /> if I am a small quantity generator)is true. <br /> Generators) u <br /> erors Printed/Typed Name tgna re on <br /> A. <br /> 16.International Shipments <br /> ❑Import to U.S. E]Export from U.S. Port of entry/exit: <br /> Transporter signature for exports only): Date leaving U.S.: <br /> W 17,Transporter Acknowledgment of Receipt of Materials <br /> � Transporter i Printedffypbd Name Signature <br /> O <br /> Q Transporter Printed/Typed Name ._.NSignature _13" Year <br /> : <br /> 18.Discrepancy <br /> 18a.Discrepancy Indk ation Space ❑ ❑Full Rejection <br /> ❑.Quantity, EJ : ,.�Residue Partial Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> L<L Facility's Phone: <br /> LL, 18c.Signature ofAltemate Facility(or Generator) Month Day Year <br /> z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU <br /> 1. 2. 3• 4 <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed(Typed Name Signature Month .:Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />