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Please print or type. (Form designed for use elite (12-pftch) typewriter) <br />i <br />Form Approved. OMB No. 2050-0039 <br />EPA Form 870422 (Rev. 3-05) Pre*us edition are obsolete. <br />TRANSPORTER'S COPY <br />UNIFORM HAZARDOUS <br />11. Gerrerator ID Number <br />2 Page 1 of <br />3. Emergency Resporse Phone <br />4. MandestrackingNumber <br />WASTE MANIFEST <br />- Y' I <br />0 J 4 VV <br />; <br />w <br />5. Ganerabls Name ad Wiling Address Generars Sitem (A dlerent tY� mailm address) <br />h <br />f`1'r <br />GenemWs Plane. 1 i <br />6. Transporter 1 Company Name <br />US. FPA1D Number �+ <br />t <br />7. Transporter 2 Conray Name <br />U.S.1!PA1D Number <br />8. Designated Facility Name and Site Address <br />U.S. EPA N Number <br />FadWs Phone:' <br />98. <br />9b. U.S. DOT Dr saipuon (including Proper Shipping Name, Hazard Cbs ; ID Number, <br />10. Containers <br />11. Total <br />12. that <br />13. Waste Codes <br />No. <br />Type <br />HM <br />. and Packing G—p (de*) <br />Quantity <br />WLNd. <br />Z <br />2 <br />W <br />0 <br />3. <br />4. <br />14. Special Handing Instructions and AdditiDnallirft"dion <br />15. GENERATOR'SfOFFEROR'S CERTI : I thereby dedam that the contents of this rorskjnment are fully and accurately described above by the proper shipping name, and are classfied, packaged, <br />narked and labek dlplacarded, and are m i sl, respects in proper condition for transport accxdkV to applicable n1webonal and national governmental regulatom if export shipment and I am the Primary <br />EWW, I m* that the contents of this cbnsignnwht conbrm to the toms of Cte attached EPA .Admowled off t of Consent. <br />I certify that the waste mnnf¢aion statement identified in 40 CFR 26227(a) (d i am a large quardky gam) or (b) fill am a small quanMy genembor) is true. <br />GenerabrslOCerors Printed/Typed Name SyRdum Month Day Year <br />16. Intemabwal Shipments Q b U.S. ❑ Expot from U.S. Port of entrylent <br />= <br />Transporter Wkdure (for exports only): Date kmvng U.S. <br />W <br />17.TrarsportaAcknowledgment ofReceipt ofMWmals <br />Transporter 1 Name <br />s9natrse Month Day Year <br />N <br />Z <br />Transporter 2 fttedrTyped Name Signature y Year <br />r <br />18. Dscrepan y <br />18s. Discrepancy Indication Space ❑ Qty <br />❑ Typo ❑ Rerid s ❑ Pallial Rejection ❑ Fulf Rejed. <br />Manifest Rte Number. <br />18b. Alternate Facility (or Generator) - - U.S. EPA ID Number <br />J <br />U <br />LL <br />FadWy's Phone: <br />W18c. <br />Sowture of Alternate Facility (or Generals <br />Month Dal' Year <br />Q <br />Z <br />19. Hazardous Waste Repot Management Me" Codes (ie., codes for hazardous waste treatment, disposal.and recycling syster s) <br />� <br />1. <br />2 <br />3. <br />14. <br />20. Desgnated Fa* Qwfier or Operator of receipt yf hazardous malwals caverpd by the mandest except as oiled in ken 18a <br />PnntedlTyped Name' Sgrhaina Mont h Day' Year <br />EPA Form 870422 (Rev. 3-05) Pre*us edition are obsolete. <br />TRANSPORTER'S COPY <br />