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Please 'nt or type.(form designed for use on elite(12-pitch)typewriter.) <br /> t.Generator ID Rumher Form Approved.OMB No.2050-0038 <br /> UNIFORM HAZARDOUS 2.Page t of 3.Emergency Response Phone 4.Manliest hacking Number <br /> WASTE MANIFEST ��� <br /> 5.Generelor's Name and Madirg Address Generators Site Address(If different than mailing address) <br /> Generelors Phone: <br /> F Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name <br /> U.S.EPA ID Number <br /> B.Designated Faclety Name and Site Address <br /> U.S.EPA ID Number <br /> Facility's Phone: <br /> ga, 9b.U.S.DOT Description(including Proper Stopping Name,Hazard Class,ID Number, t0.Containers <br /> HM and Packkg Group(if any)) 11.Total 12.Unit 73.Waste Codes <br /> 1. <br /> No. Type Quantity WWW, <br /> F <br /> K I <br /> W 2. <br /> !9 <br /> I <br /> 4. <br /> 14.Special Handling InsVuckk s and Addisonal lnfmmation <br /> 15. GENERATOR'SIOFFEROR'S CER111: A710N: 1 hereby declare that the contents of this=3191tamll are fully and accu ifely described above by the proper shipping name,and are classified,packaged, <br /> marked end labeledfplararded,and are in all respects in proper condition for transport according to applicable intemationaland nagonal governmental regWasons.If export shipment and I em Ue Primary <br /> Exporter,I certify that the contents W this consignment conform to the terms of the attached EPAAcknowledRnent of Consent. <br /> I ceNry that the waste mmmiraton statement idenfified in 40 CFR 262.27(a)(if I am a large quenutygerrerotor)or(b)(ifI am a small quantity generator)is We. <br /> GmreratursrOfiemrs PrinletlRyped Name Signature Month Day Year <br /> 1fi.InternateOal Shipments <br /> a ❑Import to U.S. ❑Export from U.S. Pod of antry/exit <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> K 17.TransponerAcknowledgmenl W Receipt of Materials <br /> Transponer t PnmedrTyped Name <br /> Signature <br /> Oa Month Month Day Year <br /> N <br /> Transporter 2 PrinledRyped Neme Signature Month Day Year <br /> H <br /> } 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantry ❑T e <br /> YP ❑Resklue ❑Portal Rejection ❑Full Rejection <br /> 18b.Allemale Facility(orGeneretor) Manifest Reference Number. <br /> J <br /> U.S.EPA ID Number <br /> U <br /> LL FacRlys Phone: <br /> w 18c.Signature olABemala Fatality(or Generator) <br /> Q Month Day Year <br /> Z <br /> H19.Hazardous Waste Report Management Method Codes(i.e.,Codes for hazardous we beaunenl,tliafmsel.and recycling systems) <br /> 4. 3. <br /> 4. <br /> 20.Designated Fadity owner or Operelon Cerbficalton of receipt of hazardous matedais cmaded by the ma 1 except as acted in Item tae <br /> Print yped Name ignalure Monty Oay Year <br /> EPA Farm 8700-22(Rev.3.05) Previous editions are obsolete. --L—L--J-- <br /> DESIGNATED, AO RTOILITYTGENEAR <br />