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"Il.. <br />Please print or type. (Form designed for use on elite (12 -Ditch) tvpewriter.l <br />.we <br />Fnrm Annrmrcd rkAIR Aln oncn-nnao <br />9 EmergencyResponse _be <br />EPA Form 8700-22(Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />2. Pae 1 of <br />3. Emer enc Phone <br />------ ---- <br />4 Manifest Tracking Number <br />WASTE MANIFEST - - <br />v1•i, , <br />J J K <br />5. Generators Name and Mailing Address Generator's Site Address (if different than mailing address) <br />Generators Phone: <br />6, Transporter 1 Company Name U.S. EPA 10 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 />gra <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wtivoi. <br />13. Waste Codes <br />No. <br />Type <br />1 <br />2 <br />2. <br />W <br />3. <br />4. <br />14. 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 labeled/placarded, 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 EPA Acknowledgment 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) (gI am a small quantity generator) istiue. <br />Generarors/Offerc(s Pri tedlTyped'Name �. Signature Month Day Year <br />F— <br />16. International Shipments <br />❑ Import to U.S. ❑ Fxpon from U.S. Foretell ti <br />Transporter signature (for exports only): Date leaving U.S.: <br />w <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 PrntedlTyped Name Signature Month Day Year <br />O <br />13- <br />W <br />¢Z <br />Transporter Printed/Typed Name Signature Month Day Year <br />K <br />F <br />18. Discrepancy <br />I <br />like. Discrepancy Indication Space ❑ Quantity ❑ Type ElResidue❑Partial Rejection ❑Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />U <br />LL <br />Facility's Phone: <br />W <br />18c. Signature of Affemate Facility (or Generator) <br />Monty Day Year <br />Z <br />y19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />G <br />1. <br />2. <br />20. Designated Fadlity Owner or Operator' Certification of receipt of hazardous materials covered by the manifest except as noted in Item 183 <br />1 <br />Pnnted/Typed Name Signature Month Day Year <br />EPA Form 8700-22(Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />