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Please print or type Form Approved.OMB No.2050-0039 <br /> • UNIFORM HAZARDDUS 1,Generator lD 2Page7 of 3.Emergency Response Phone 4.Manliest Tracking Number <br /> WASTE MANIFEST Number <br /> S.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Generator's Phone: <br /> ® 6,Transporter l Company Name U.S.EPA ID Number ��, • <br /> 7.Transporter 2 Company Name U.S.EPAID Number <br /> • B,Designated Facility Name and Site Address U.S.EPAID Number ��, • <br /> ® Facility's Phone: <br /> ga go US.OCT Description(including Proper Shipping Name,Hazard Class,l DNumber, 10.Containers 17.Total Unit® HM and Packing Group(if any)) 12. 13.Waste Codes <br /> No. Type Quantity Car No. <br /> 1. <br /> ¢0¢ a <br /> • w 2 <br /> as <br /> • 3 • <br /> • 4 em ..m �'i • <br /> • 14,Special Handling Instructions and Addoanformation • <br /> 15. GENERATOR'SIOFFERORS CERTIFICATION:l hereby decl true con is coin gruni y and acauretey described above by the proper name,and are dasslfietl,packaged, <br /> • marked and labeleNplecardetl,end are In all respects In properc <br /> In trans b "i- einlernational end national governmental regulatiene,If export shipment antll em the Primary • <br /> Expuger,l certify that the contents of this consignment conform to sof the arta 'p no edgmentof Consent <br /> certifyfhatthe wast minimization stalemant <br /> in <br /> In 40 CFR (a)(ifl am elarge quantitygenerator)or(b)(Ifl am asmall quantity genarator)Is true. <br /> Generator's/OBerors Printedfryped Name ignature onth Uay Year <br /> • International Shipments <br /> i...q <br /> z ❑Import to US ❑Export from U.S. Port of entrylexit <br /> Transporter signature(for exports only), Dale leaving U.S.: <br /> • as 17,TransporlerAcknowedgment of Recelptof Matelots • <br /> K Transporter 1 PrinteTTyped Name Signature Month Day Year <br /> a <br /> n <br /> ® 4 Transporter 2 ParrodfFyied Name Signature Month Day Year 1, <br /> K <br /> r— <br /> 10.Discrepancy <br /> ® 10a.Discrepancy Indication Space • <br /> ❑ Quantity ❑Type Rest due ❑PaNal Rejection ❑Fall Reaction <br /> ® Manifest Reference Number', <br /> Isis Alternate Facility(or Generator) U.S.EPAID Number <br /> U <br /> rat. Facility's Phone: <br /> ® wIds,Signature of Alternate Facility(orGenerator) <br /> Month Day Year • <br /> Z <br /> as 10.Hazardous Waste Report Management Method Codes Him,codes for hazardous waste treatment,disposal,andrecyelingsyatems) <br /> • 0 1. 2. 3. �4, • <br /> 20.Designated Parity Owner or Operator:Contrarian of receipt of hazardous maPariNs covered by the manifest except as noted In Item 16a <br /> • nne <br /> epoo Name MlMontl Day Year • <br /> EPA Form 8700-22(Rev,12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br /> ® 81 of�98• <br />