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Please print or type. (Form designed tar use on elite !ch) typewriter.) Form Approved OMB No, 2050-0039. <br />Style CF is LMELFIASMW(M)w1390a wxw.lemlmastersom EPA Form 870022A (Rev.9-88) Previous editions are obsolete. <br />M„ feA �,e�� GENERATOR COPY <br />UNIFORM HAZARDOUS <br />21 Gene,—Js US EPA ID No. Manifest Document No. <br />«. Page <br />Information in the shaded <br />WASTE MANIFEST <br />areas is not required by Federal <br />(Continuation Sheet) <br />1 I I ., l <br />law. <br />23. Generator's Name, <br />L. State Manifest Document Number <br />M. State+ Generator's ID <br />24.. Transporter Company Name 25. US EPA ID Number <br />N. State Transporters ID <br />- L i <br />O. Transporters Phone <br />26. Transporter _Company Name 27, US EPA ID Number <br />P. State Transporters ID <br />O. Transporters Phone <br />28. US DOT Description (Including Proper Shipping Name, Hazard Class, and /D Number) <br />29. Containers <br />30. <br />Total <br />1. <br />U3nit <br />R. <br />Waste No. <br />HM <br />No. T e <br />Ouaoht <br />Vii <br />a. <br />r <br />b. <br />C. <br />G <br />d. <br />E <br />N <br />E <br />R <br />A <br />a. <br />T <br />0 <br />R <br />I. <br />9 <br />h. <br />i. <br />S. Additional Descriptions for Materials Listed Above <br />T. Handling Codes for Wastes Listed Above <br />32. Special Handling Instructions and Additional Information <br />T <br />R <br />33. Transporter Acknowledgement of Receipt of Materials <br />Date <br />Printedlfyped Name <br />Signature <br />Month Day Year <br />N <br />S <br />P <br />o <br />R <br />34. Transporter _ Acknowledgement of Receipt of Materials <br />Date <br />Printed/Typed Name <br />Signature <br />onth Day Year <br />E <br />R <br />F <br />A <br />35. Discrepancy Indication Space <br />c <br />L <br />T <br />Y <br />Style CF is LMELFIASMW(M)w1390a wxw.lemlmastersom EPA Form 870022A (Rev.9-88) Previous editions are obsolete. <br />M„ feA �,e�� GENERATOR COPY <br />