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Please print or type. (Form designed for use on elite (12-pdch) typewriter) <br />Form Approved. OMB No. 2050-0039 <br />MIA roan 8700.22 (Rev. 3405) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />UNIFORM HAZARDOUS <br />I. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest 7ncking Number <br />WASTE MANIFEST <br />J J K <br />5. Generators Name and Mailing Address Generators Site Address (it different than mailing address) <br />Genial Phone:. <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />7. Transporter 2 Company Name U.S. EPAID Number <br />B. Designated Fal Name and Site Address U.S. EPA ID Number <br />Fal Phone: <br />ga. <br />9b. U.S. DOTDesaipfion (inducing Proper Shippng Name, Handed Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />HM <br />and Fall Group tif anal <br />Dumbly <br />Ag Not. <br />13. Waste Codes <br />No. <br />Type <br />d' <br />O <br />Q <br />w <br />z <br />2. <br />Ila <br />f7 <br />3. <br />4. <br />14. Spada] Handling Instructions and Additional Intortnation <br />15. GENERATOR'SIOFFFROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, an are dassdied, packaged, <br />marked and IabeleNplacarded, and are in all respects in proper condition for transport according 0 applicable international and national governmental regulations. t export shipment and I am the Primary <br />Exporter. I certify that the contents of this consignment conform to the terns of the attached EPAAcknowledgment of Consent. <br />I certify that the waste minimization statement identified he 40 CFR 262.27(x) (t I am a large quantity generator) or (b) (til am a small quamily generator) is true. <br />GeneratorslOterors Printedrryped Name Signature Month Day Year <br />�j16. <br />thtemationai Shipments <br />❑ Import to U.S. ❑ Export tam U.S. Pod of enbylexit <br />K <br />Transporter signature(for exports only): Date leaving U.S.: <br />w <br />17. Transporter Acknowledgment of Receipt of Materials <br />W� <br />Transporter 1 Printeayped Name Signature MOO Day Year <br />o <br />a <br />n <br />K <br />Trsnsporter2 PnnteMyped Name SignaNre Month Oay Year <br />h— <br />} <br />1a. Discrepancy <br />8x. Discrepancy Indimlion Space <br />El Quantity [—]Type❑ ResHue ElParfial Rejection ❑ Ful Re)ecton <br />Marifast Reference Number. <br />> <br />F <br />18b. Alternate Facility (or Generator) U.S.EPAIDNumber <br />J <br />U <br />torr.. <br />Facl Phone: <br />W <br />18x. Signature of Alternate Facility(or Generator) <br />March Day Year <br />a <br />z <br />y19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />1. <br />2. 3. <br />4. <br />20. Designated Faality Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as road in Rem 1 B <br />PrinteciTyped Name Signal Month Day Year <br />MIA roan 8700.22 (Rev. 3405) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />