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-Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.205Oa39 <br /> UNIFORM <br /> 1.Generator ID Number 2.Paged of 3 Emergency Response Phone 4.ManifestyyT��racking Number (Qy y <br /> W SE MANIFEST OUS i � .P C7 ��K <br /> Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> Generators Phone: <br /> 6.Transporter l Company Name, U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Facility's Phone: <br /> ge 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM <br /> and Packing Group(if any)) No. Type Quantity WLNOL 13.Waste Codes <br /> 1. <br /> K <br /> 2 2 <br /> W <br /> 3. <br /> 4. <br /> t.Special Handling Instructions and Additional Information <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 Iabeledlplacarded,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 terms of the attached EPAAckooWedgment 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 am a small quantity generator)is time. <br /> Generators/Offe bes Pdnte Irryped Name Signature Month. Day Year <br /> —s 16.Intemafional Shipments <br /> p_ El Import to U.S. Dawn U.S. Port of entryleilt: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> but 17.Transporter Acknowledgment of Receipt of Materials <br /> �E Transporter 1 PdntedfTyW Name Signature Month Day Year <br /> O <br /> a <br /> QTransporter Pn6ted7fyped Name Signature Month Day Year <br /> a' <br /> r <br /> 4. 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residuej j <br /> Partial Rejection Full Rejection <br /> Manif u <br /> 18b.Alternate Facility(or Generator) m' . . r <br /> J <br /> Facility's Phone: <br /> MAY 0 2 OtI <br /> u, 18c.Signature ofAltemate Faciliy(or Generator) Month Day Year <br /> z EINVIMNMEIvTAL HEALTH <br /> 1- Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling s ems <br /> L 2. 3. 4. <br /> G <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered byte manifest except as acted in Item 18a <br /> Ponfed?yped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />