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�)XAJ'w <br />Please orint aivce. (Form designed for use on elite (12-oilch�ewriter.) <br />V111 <br />\� Form Approved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />-„ <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />WASTE MANIFESTS <br />�� 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 ID Number <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />B. Designated Facility Name and Site Address U.S. EPA ID Number <br />Facility's Phone: <br />9a, <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 />Wtivol. <br />13. Waste Codes <br />No. <br />Type <br />1. <br />C <br />r . . <br />Z <br />2. <br />W <br />3. <br />l <br />4. <br />14. Spatial Handling Instructions and Additional Intonation <br />15. GENERATOR'S/OFFEROR'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 acwrding 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 cemy that the waste minimization statement iderafled in 40 CFR 262.27(a) (H I am a large quantity generator) or (b) If I am a small quantity generator) is true. <br />GeneratorslORerors Printedrfyped Name Signature Month Day Year <br />J <br />� <br />16. International Shipments <br />❑ Import to U.S. ❑Export from U.S. Port <br />of entry/exit: <br />Transporter signature (for exports only): Date leaving U.S.: <br />Liu <br />17. Transporter Acknowledgment of Receipt of Materials <br />OTrenspoder <br />1 Printed/Typed Name Signature Month Day Year <br />a <br />Z <br />Transporter Pnntedrryped Name Signature Month Day Year <br />K <br />H <br />} <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Par al Rejection ❑ Full Rejection <br />Manifest Reference Number. <br />rep. Alternate Facility Generator) <br />(or U.S. EPA ID Number <br />J <br />U <br />LL <br />Facility's Phone: <br />w <br />18c. Signature of Alternate Facility(or Generator) Month Day Year <br />Q <br />Z <br />H19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />p 1. <br />2. 3. <br />4. <br />20 <br />Designated Facility Owner or Operator: Certificetion of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printedriyped <br />1 <br />Name Signature Month Day Year <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />