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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phoned.Manifest Tracking Number �(c <br /> WASTE MANIFEST S fill <br /> 5.Generators Name and Mailing Address Generalafs Site Address(it different than mailing address) <br /> Generator's Phone. <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7 Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Facility's Phone: <br /> 9a 91d.U.S.DOT Description(including Proper Shipping Name.Hazard Class.10 Number, t(1Containers 1 t Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(ff any)) No. Type Quantil') �:S.VN <br /> 1. t <br /> 0 <br /> O <br /> r <br /> w <br /> z <br /> U.1 <br /> t7 <br /> S I <br /> 14,Special Handling Instructions and Additional Information <br /> 15. GENERATOR'SIOFFEROR'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 labeledlplanarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I cattily that the contents of[his consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(d I am a large quantity generator)a(b)(d I am a small quantity generator)is true. <br /> Generatorsl0ffevors Pninted7Typed Name Signature Month Dai Year <br /> 16-International Shipments <br /> � ❑import to U.S. ❑Export from U.S. Port o!enlrylexiC <br /> Transporter signature(for exports only): <br /> Date leaving U.S.' <br /> U= 17.Transporter Ackrw,vledgment of Receipt of Materials <br /> ¢ Transporter t Pnnted/Typed Name Signature Month Day Year <br /> O <br /> a <br /> Z Transporter 2 Pnnledlfypetl Name Signature Month Day veer <br /> a <br /> nd <br /> 18.Discrepancy <br /> 1 18a Discrepancy Indication Space 1:1Quantity ElType ElResidue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Amemale Facility(or Generator) U.S.EPA ID Number <br /> M <br /> U <br /> Facility's Phone' <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> 2 <br /> c7 19.Hazardous Waste Re Management Method Codes i.e.,codes for hazardous waste treabmenL di recycling systems) <br /> � 0� 9 ( disposal,and 1' s ems <br /> 20.Designated Facility Owner or Operator:Certiftualon of receipt of hazardous materials covered by the manifest except as noted in Item 1 Ba <br /> PrintedfTyped Name Signature Month pry Year <br /> EPA Form 8700-22(Rev.3-05)Previous editions are obsolete. GENERATOR'S INITIAL COPY <br /> RE . E,IV E D <br /> MAY 19 2017 <br /> ENVIRONMENTAL HEALTH <br /> DEPARTMENT <br />