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Please print or type. Form Approved.t3M8 No.205RA039 <br /> UNIFORM HAZARDOUS 1 Gerrerat&ID Number 2.Page 1 of 3 Emergency Response Phone 4.Whitest Tracking Number <br /> WASTE MANIFEST J J K <br /> 5.GenuratVs?Mame and Mailing Address Generato?s Site Address(if different than mailing address) <br /> Gtrieraioes Phone <br /> F Transporter t Company Name U.S.EPA ID Number <br /> y> • a 9 <br /> ?.Trsnsporter 2 Company Name U.S.EPA ID Number <br /> x <br /> 8 Designated Family Name and Site Address U.S.EPA ID Number <br /> Fac lity's Phone: <br /> 8a. $b.U.S-DOT Description{including Proper Shipping Name,Hazard Class,ID Number, ID.Containers 11.Total 12.Unit <br /> Hk1 and Packing Group(if any)) No. Type Quanttty Wtivo1. 13.Waste Codes <br /> 1.. <br /> O _ _ <br /> 3 <br /> 13.Speoia!Handling Instructions and Additional Information <br /> 15. taENERATOR'&OFFEROR'S CERTIFICATION; I hereby declare that the confertus of this consignment are fully and aeeuratery described above by the proper shipping name,and are classified.packaged. <br /> marked and labeled!placarded.and are in all respects in proper condition for transportaccording to applicable international and national governmental regulat£ons-1f exportshipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terns of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minim€zation statement identified in All CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generatorl is true. <br /> Generatafs?Gfferols Printedlfyped Name Signature Month Day Year <br /> 16.Iniernationai Shipments <br /> I�r�'`� <br /> t Import to J.S. ❑Export from U.S. Port of etntrylexit: <br /> ? Transporter signature(for exports only): Dale leaving U.S.: <br /> W. 17 Transporter A&riuwledgntent of Receipt of Materials <br /> w <br /> t& Transporter t Printed.typed Name Signature Month Day Year <br /> O <br /> 2 Transporter IAnnied.yXied Name Sigraturi Month Day Year <br /> 9 <br /> IB.Discrepancy <br /> 1 Sa.Discrepancy Indication 5pacoG �� <br /> Quantityi_._.I Type Residue f.—i Partial Rejection Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator; U.S.EPA ID Number <br /> V <br /> LL. FaclVs Phone: <br /> Signature of AIL-mate Fackity for Generator) Month Day Year <br /> 13.Haazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment!,disposal,and recyclfrg systems) <br /> G 1. <br /> 26.Designated Facility Omier or Operator GerIttication of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PnrtedlTyped Name Signature Month Day Year <br /> EPA Form 87170-22(Rev.12-17) Previous editions are obsolete. GENRATOR`S INITIAL €OPY <br />