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re print or type. (Form designed for use on elite (12 -pitch) typewriter.) <br />-e ol"I'll <br />t�T UNIFORM HAZARDOUS 1 1. Generator ID Number <br />DO <br />c:— A --i nxiD Ni gnan nnin <br />Form 8700.22 (Rev. 3-05) Previous editions are obsolete. 7" ^fe:.N VF -D -FACILFY 7 <br />2. Page I of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />WASTE MANIFEST <br />JJK- <br />5. Generators Name and Mailing Address <br />Generator's Site Address (if different than mailing address) <br />Generator's Phone, <br />6. Transporter 1 Company Name <br />U.S. EPA ID Number <br />7. Transporter 2 Company Name <br />U S. EPA ID Number <br />8 Designated Facility Name and Site Address <br />U.S. EPA ID Number <br />Facility's Phone: <br />9a. <br />9b. U.S. DOT Description (including Proper ShiName, <br />pt <br />Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (it any)) <br />Quantity <br />WLAADL <br />2. <br />4, <br />14 Special Handling Instructions and Additional Informstiol <br />A: <br />5. GENEPATOR'SIOFFEROR'S CERTIFICATION: I heteby <br />declare that the contents of this consignment are fatly and accurately described above by the proper stripping name, and are ciassified, packaged, <br />marked and labeled1placarded, and are in all respects <br />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 thu consignm er"I <br />conform to the terms of the attached EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement identified <br />in 40 CFR 262.27(a) I am a large quantity generator) or (b) (d I am a small quantity generator) is true, <br />Generators/Offenor's PrintedfTyped Name —7 <br />Signature <br />Month Day Year <br />16. internal onal Shipments El Import to U.S. ❑EWt from U.S. Port of entry/exit <br />Transporter signature (for exports only): Da -.e leaving U.S.: <br />17. Transporter Acknowleedgirmnt of Receipt of Materials <br />Transporter 1 NntedFryl>ed Name Signature <br />Month Day Year <br />Transporter P PrintediTyped Name Signature <br />Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Spare 0 Quantity OTYP' Residue ❑ Partkt Rejection <br />L1 Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) 0 S. EPA ID Number <br />FarAlity's Plwe: <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />19. Hazardous Waste Report Management Method Codes (i.j., codes for hazardous waste treatrnent, disposal, and recycling systems) <br />1. <br />1 2. 1 -13 <br />4. <br />20. Designated Facility Owner or Operator-, Certification of rec6pl of hazardous materials coven.d by the manifest except as noted in Item 1 aa <br />PflntodflypeO Name Signature <br />Mofdh 0" ear <br />Form 8700.22 (Rev. 3-05) Previous editions are obsolete. 7" ^fe:.N VF -D -FACILFY 7 <br />