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type . (Form designed for use on elite (12-pitch) typewriter.) Form Approved. OMB No. 20504039
<br /> >NIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. MjaoHest T.r�ackiI Number.,lh`
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<br /> ' WASTE MANIFEST ( +' " Co `?
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<br /> tot s a d hjail'yg Address GanertOfs Site Address (i1 different than mailing address)
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<br /> Generators Phone: U.S. EPA ID Number
<br /> 6. ransp Rer 1 Company Name
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<br /> Transporter 2 Company Name U.S. EPA ID Number
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<br /> Oey"gnat{ FRdtity Name, and S'tte P� dress U.S. EPA ID Number
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<br /> Facility's Phone: t!iG - �^ fr, `s • `' `! r,
<br /> 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class. 10 Number, 10, Containers 11 . Total 12. Unit 13, Waste Codes
<br /> 9a No. Type Quantity WtNol.
<br /> HM and Packing Group (1 any))
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<br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the rwntants of this consignment are fully and accurately described above by the propershipping came, and are dassiied, packaged,
<br /> marked and labeledlplace(ded, and are in all respects in properccnd'rtion for transport according to applicable international and national governmental regulations. If export shipment and t am the Fdmary
<br /> Exporter, l certify that the contents of this consignment conform to the terms of the attached EPAAcknoWedgment of Consent
<br /> I certify that the waste minimization statement Identified in 40 CFR 262.27(a) (if f am a large quantity generator)or (b) (if I am a small quantity generator) is We.
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<br /> .ail 16. IntemationalShipments
<br /> ❑ in. to U.S. © Export from U.S. Port of entrylexit:
<br /> 2 Transooner stanature (for exWs only): Date leaving U.S.:
<br /> w17, Transporter Acknowledgment ofReceipt ofMatedals
<br /> t2 Transporter 1 PdntedfTyped Name Knalue ,� nth ay Year
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<br /> Transporter 2 Printed/Typed Name Signature Month Day Year
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<br /> 18. Discrepancy
<br /> 18a. Discrepancy Indication Space Fail Ouantity ❑ Type ❑ Residue ❑ j ❑ - ll Rejection Partial Re edi0n Full
<br /> Manifest Reference Number.
<br /> Iso. Atemate Facility (or Generator) U.S. EPA ID Number
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<br /> W / 8c. Signature of Alternate FaraTc/ (or Generator) , M t�h" Day Year
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<br /> 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) SEPTU 0 16
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<br />[ 20. Designated facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a
<br /> Printed?yped Name SignatureY
<br /> Month Oa Year
<br /> EPA Form 6700.22 (Rev. 3.05) Previous editions are obsolete. GENERATOR'S INITIAL COPY
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