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PI dnt orp, a (Form designed for use on elite (12-pitcl j) pewriter ) <br />Form Approved. OMB No. 2050-0039 <br />easel <br />P . <br />1. GenemterlD Number <br />2. Pageh of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />UNIFORM HAZARDOUS <br />- - <br />OO <br />®AT <br />WASTE MANIFEST <br />S. Generators Name and Mailing Address Generators Site Address (rfditerent than mailing address) <br />6. Transporter 1 Company Name <br />U.S. EPA ID Number <br />7. Transponer 2 Company Name <br />,t_- <br />U.S. EPA ID Number <br />8. Designated Facility Name and Site Address <br />U.S. EPA ID Number <br />FacifitVs Phone:._ - "... <br />... .. <br />ga <br />91b. U.S. DOT Description (including Proper Shipping Name, 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 df any)) <br />Quantity <br />WWoI. <br />1 <br />f•� <br />Z <br />2. <br />W <br />C7 <br />3. <br />4. <br />14. Special H$htlling Instiupbot{s ah�Addldonal Information <br />15. GENERATOR'SIOFFEROWS CERTIFICATION: I hereby declare that the contents of this consignment am fully and accurately described above by the proper shipping name, and are dassil ed, packaged, <br />marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulators. If export shipment and I am the Primary <br />- <br />� !my 9 edgment Consent. <br />terns of the attached EPAAfty <br />. <br />gen <br />82.27(x) Of I am a large quantlly generator) ur (b)(81 am a small quantity generator) is true.- <br />f ready, that Bre waste merrmiratlonoalinement Identified In 40 CFR 2e (b <br />Genterators/OI(erces Pdntedrryped Name Signature <br />Month Day Year <br />78:1 ational Shipments " <br />❑Import to U.S. ❑Fxpodfrom U.S. Pod of a' <br />Transporter signature (far exports only): Date leaving U.S.: <br />w <br />17. Transporter Acknowfedgment of Receipt of Materials <br />Transporter 1 Printed/Typed Name Sgnature, - <br />Month Day Year <br />oDay <br />GTransporter <br />2 Printed/Typed Name Sgnatore <br />Month Year <br />18: Discrepancy - <br />18a. Discrepancy Indication Space ❑ Quantity Type ❑ T ❑Residue <br />El PaNal Rejdone <br />❑Full Rejector <br />-Manifest Reference Number. <br />18b. Alternate Facility(or Generator) <br />U.S. EPA ID Number <br />J <br />U <br />LL <br />FadlBys Phone: <br />- _. ______._-_—__ <br />--___MoNh_.__Day..__Year <br />y�j18c,SignatoreofAlternate-FadWy{ocGenerator)____.___-. <br />a <br />z <br />y19. <br />Ha Nous Waste Report Management Method Codes d e, codes for hazardous taste treatment, disposal, and recycling systems) <br />C <br />1. ( f ( <br />2. 3 <br />4. <br />20 Designated Facility Ovmer or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in herd 188 {, <br />Pmlled typed Name Signature <br />Month Day Year <br />1 <br />l'. y e. <br />EPAFolm 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />