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<br /> Please print or type.(Ft)rm designed for use on elite(12-pitch)typewriter.) Form Approved,OMB No,2050.0035
<br /> UNIFORM HAZARDOUS 1 Generator ID Number 2 Page i of 3 Emergency Response Phone A Mantfesi Tracking Humber
<br /> WASTE MANIFEST
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<br /> 5,Gonamtor's Name and Mailing Address Generator's S;1e Address(it different than mailing address)
<br /> Generalor'sPhone. >, i
<br /> 6.Transporter 1 Company Name U.S,EPA ID Number
<br /> 7,Transporter 2 Company Name U.S,EPA ID Number
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<br /> S:Designated Facility Name and Site Address U.S,EPA ID Number
<br /> Facility's Phone?'"
<br /> ga, 9b,U.S:DOT Description(inducing Proper Shipping Name,Hazard Class,ID Number, 10,Containers 11.Total 12.Unit 13,Waste Godes
<br /> HM and Packing Group(if any)) No. Type Quantity 'Nt.IVot,
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<br /> ?d.Special Handling Instructions and Additional Information
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<br /> 15. GEHERIITOR'SIOFFEROR'S CF-RTIFICATION I heraby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,arwi are classified,packaged.
<br /> marked and labaled?piacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.it export shipment and i am the Primary
<br /> Expoder,I certify that the contents of this consignment conform to the terms ofthe attached EPA Acknowledgment of Consent.
<br /> I vilify that the vrasta minimization statement Identified in 40 CFR 262 27(a)(if I am a large quantity generator)or(b)(ifI am a small quantity general or)is true,
<br /> GaneratoPslOfferoes PriniediTyped Name Signature Month Day Year
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<br /> -j 16.International Shipments rt from U.S.. Port of entry/exit. �
<br /> F El Import to U.S. F]E>� !`
<br /> Transporter signature(for exports only): Date leaving U$,ti
<br /> 17.Transpo terAcknoyAo gm�ni of R$ceipt pf Matena(e
<br /> Trend dear 1 Patnkxtr7yped erne41
<br /> 1, 7SignaY w x Moth Day Year
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<br /> Transpo t a2 Pnnted ypey( 1ama „�Stgnature :Morn a Day Year
<br /> fit Discrepancy ""t�T r--�
<br /> i8a,Discrepancy Indication Space Quantity I T t_1 Full Rejection
<br /> _ Ty ❑Residue Partial Rejection i
<br /> Manifest Reference Number:
<br /> 181),Attemate Facility(or Genera'tr>r) U,S,EPA ID Number
<br /> cam Facility's Phones
<br /> 18c,Signature of Alternate Facility(or Generator) Month Day Year
<br /> its.Hazardous Waste report Management Method Codas(i.e.,codes for hazardous waste treatment,disposal,and recycling systems)
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<br /> 20.Designp)ed`Feality dvrner or Operator.Certi6ratton of recaipt of hazardous materials covered by the map6est exedpt as noted In item 18a
<br /> Printed/Typed NaojeSignature,:- Adantn Day tYaar
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<br /> EPA Form 8700-22(Rev.Ywj Previous editions ani:obsolete,
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