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Form Approved. OMB No. 2050-0039 <br />Please <br />pont or type. (roan aesigneu or use un anm t,v1w11j vi -w,,-1,;.. <br />1. Generator ID Number <br />2. Pagelaf <br />3. Emergency Response Phone <br />- - <br />4, ManifestTracking number <br />UNIFORM HAZARDOUS <br />00 <br />DAT <br />MANIFEST - <br />5. Generator's Name and Mailing Address Generators Site Address Off different man <br />mailing address) <br />6. Transporterensporter 1 Company Name <br />Transporter <br />U.S. EPA ID Number <br />TT Company Name <br />U.S. EPA ID Number <br />8. Designated Fadlity Name -and Site Address <br />U.S. EPA ID Number <br />Facilmjs Phone: - <br />ga <br />9b. US. DOT Description (including Popper Shipping Name, Hazard Class, 10 Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Pecking Group (if any)) <br />Quantity <br />WLIVa1. <br />O <br />) <br />^ To, <br />. <br />out <br />3. <br />rr� <br />4. <br />TE <br />-L <br />-L- <br />14. Special Handling Instmclions and Additional Informadon <br />15.. 'GENERATOR'SIOFFER OR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately descnhed above by the proper shipping name, aid are <br />classified, packaged, <br />marked and labaledlplararded, and are in all respects in popper condition for transport according to applicable international and national governmental regulations. If export shipment and <br />I am the Primary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br />I certily that the wasteinfNmizaeon statement identified in 40 CFR 26227(a) ('d I am a large quantity generator) or (b) (dl am a small quantity generator) is We. <br />Generatofs/Offemr's Pnntedrryped Name 51gnatura <br />Month Day Year <br />J <br />r <br />16, Intemalldna Shipments <br />❑ Import to U.S. ❑ Export from U.S. Port ofentry/exit <br />" <br />= <br />Transporter signature(for exports only): Date leaving U. S. <br />17. Transporter Acknowledgment of Receipt of Materials <br />Signature <br />Month Day Year <br />Transporter 1 PdntsdfTyped Name <br />ir <br />Q <br />TraniPdnted/Typed Name Signature <br />Mon Day ear <br />18. Discrepancy -- <br />18a. Discrepancy Indication Space❑ T ❑ ❑ Residue <br />Quantity yce <br />❑ Partial Rejection <br />ElFullRejection <br />Manifest Reference Number: <br />186. Alternate Facility for Generator) <br />- U.S. EPA ID Number <br />7 <br />U <br />ser- <br />Faeilitys Phone: <br />w <br />18c. Signature of/iltemate Facility (or Generator) <br />Month Day Year <br />a <br />z <br />y19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />LM <br />1. <br />2. 3. <br />4, <br />20 Designated Feality, Omer or Operator. CeN6cation of receipt of hazallous materials covered by the manifest except as ndar),in Item 18a <br />1 <br />PnntedRyped Name Signature <br />Month Day Year <br />EPA Form 6700-22(Rev.3-05)Predious editions are obsolete. - DESIGNATED FACILITY IJ GENERATOR <br />