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Please print or type.(Form designed for use on elite(12-pitch)tMviller.) Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Pap I of 3.Emergency Response Phoie Mantled Tracking Number <br /> WASTE MANIFESTw .-0 i - A <br /> I " . 1p - .1� 1 . 1 .t���' V'l 4� .-.'.�-Ie 48069 1 <br /> 5.Generators Name and Mailing Addres3 Generator's Site Address(if dif4rent than mailing address) <br /> Generator's Phone: <br /> 6.Transporter I Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Slte.Address U.S.EPA ID Number <br /> FacRiys Phone: <br /> 9a. 9b-U.S-DOT Description(incluGing Proper Shipping Name,Hazard Class,ID Number, 10.Contairers 11.Total 12.Unit 13.Waste Codes <br /> H&I and Packing Group(f any)) No. Type Quantity WtJV0l- <br /> 0 <br /> C s ' <br /> 2. <br /> LIJ <br /> 4. <br /> 14.Special Handling instructions and Additional information <br /> 15. GEREMTWSIOFFEROFrS(;EKrIFICATION:I hereby declare that the contents of this consignment are fully and accurately dpscr:,ed above by the proper shipping name,and are classf cod,packaged, <br /> marked and labeled/placarded,and are in all respects inproper condition for transport accorcling to applicable internationaland natons govemmeitall regulalfor-s.If export shipment and I z4oite Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA of Consent - <br /> i mrfify that the waste minimtoliw,statement Identified Li 40 4FR 26227(a)(it I am a large quanft generator)or(b)(if I am a sr.,.dl.q-alitilly <br /> gerocator)Is true. <br /> Gew4cc?V0fferoftRrin(ed1Typed I-Otra� Signature mo*t Day Year <br /> -j 16.'Intemallainal Shipments <br /> F- [I Import to U.S. ElExport from U.S. Port of eftii-01, <br /> ?= Transportai signature(for exports ony): Date leaving'j.S.: <br /> ICE 1 T.Transporter Acknowrledgment of Rcaiot of Materials <br /> Uj <br /> I Signature Month Day Year <br /> ,T� Transporter i.PrintedifTyped Name <br /> Q Transporter 2 PrinwiTyped New SignaW Momh Day Year <br /> 18,Discrepancy <br /> 18s.Discrepancy Indication Space 0 c..* El Type EIResidua El Part i Reia,*. r1 Full Rejection <br /> Man"Reference Nwtber <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> Facilitys Ph..: <br /> LO18c.Signature of Alternate Facility <br /> U Generator) <br /> 19.Hazardous Waste Report Manali-mant Method Codes for hazardous waste treatment,disposal.and recycling systems) <br /> L in 3. <br /> U <br /> 20.Designated Facility Owner or Operator.Certification of receipt=i hazardous materials covered by the manifest except as noted in K=i 3a <br /> PdnWffyped.Namg Signature Month <br /> Year <br /> EPA FofrnS700-22'(Rev.3-M) Prev iot:s editions are obsolete. <br /> TRANSPORTER'S COPY <br />