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- t. <br />;e pnnt or type. (corm aesignea <br />Tar use on erste (iapnc) <br />typewnter.) npp.—.. -- — —.-- <br />UNIFORM HAZARDOUS <br />1 Generator ID Number <br />// <br />�Pageof <br />3. Emergency Response Phone----r4—manifest <br />j <br />Tracking Number <br />-11r+ F— r— <br />1 <br />WASTE MANIFEST <br />�r�� <br />? <br />% i.�--u4 <br />a r V 'v' r fr <br />5. Generators Name and Mailin Add <br />9 <br />�/J��i%�/f'/' l <br />i Generators Site Address if ifferent thtirt maili address) <br />�'�/�✓• � <br />Generator's Phone: — <br />6. Transporter 1 Compan Name <br />U.S. EPA ID Number <br />sclD <br />�' -,� S. <br />7. TranWer 2 Company me <br />U.S. EPA ID Number <br />B. Designated FFaacilig Name and Site Address <br />U.S. EPA ID Number <br />Facility's Phone <br />" <br />93 <br />9b. U.S. DOT Description (including Proper Shipping <br />, Hazard Class, ID Number, <br />10. Containers <br />11, Total <br />12. Unit <br />13. Waste Colles <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />f(/t)' <br />v <br />L <br />2. <br />I <br />3. <br />4. <br />14. Special Hard' Ing4ucLmandAddit onal Information_ <br />U.�\r- `\ <br />/ I fi - r. S r r lee. 1 r �Y 4% i Je, <br />• Ir• r tY <br />15. GENERATOR'SIOFFEROR'SkgRTIFICATION: I hereby <br />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/p!ac ed, and are in all respects in p <br />oper condition for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary <br />Exporter, I certify that th contents of this consignment cor <br />form to the terms of the attached EPAAcknowledgment of Consent. <br />I certify that the waste minimization statement identified in <br />Q CFR 262.27(a) (if I am a large quantity generator) of (b) (if I am a small quantity generator) is true <br />3eneralors/ORerors Printed/Typed Name <br />Signature ' / Month Day Year <br />( <br />16. Intema nal Shipments <br />❑Import to U.S. <br />�' <br />❑Export (cars U.S.' ' ' Port of entry/exiC <br />Transporter signature (for exports only): <br />Date leaving U.S.: <br />17. Transporter Acknowledgment of Receipt of Materials <br />'ransporter 1 Prinled/ryped Name <br />Signature Month Day Year <br />rransporter 2 Printed/Typed Name ` Sigrture / Month Day Year <br />i <br />18. Discrepancy <br />18a. DiscrepancyIndication Space p ❑ Quantity ❑Type ❑Residue ❑ Partial Rejection ❑Full Rejection <br />Manifest Reference Number: <br />i8b. Alternate Facility (or Generator) <br />U.S. EPA ID Number <br />:acility's Phone: <br />8c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />FiI_ <br />2. <br />!0. Designs a ' Owner or Operator: Certification of r ' ibt of hazardous materials covered by the manifest except as noted m Item 18a <br />rrinted/Typ .. •; / y Signature Month Day Yex <br />-orm 8700-22 (Rev. 3-05) Previous editions are obsoleje. DESIGNATED FACILITY TO GENERATOR <br />