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Please print or type. Form Approved OMB No. 2050039 <br /> UNIFORM HAZARDOUS <br /> 1 . Generator ID Number 2. Page 1 of 3. Emergency Response Phone 14, Manifest Tracking Number <br /> JJ <br /> WASTE MANIFEST " s <br /> 5, Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br /> IV <br /> Generator's Phone: <br /> 6, Transporter 1 Company Name U.S. EPA ID Number <br /> 7, Transporter 2 Company Name U.S. EPA ID Number <br /> 8, Designated Facility Name and Site Address U.S. EPA ID Number <br /> Facility's Phone: <br /> ga, 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Total 12, Unit 13, Waste Codes <br /> HM and Packing Group (if any)) No. Type Quantity Wt.N01. <br /> O <br /> Z 2. <br /> w <br /> 0 <br /> 3. <br /> I <br /> i <br /> 4. <br /> 14. Special Handling Instructions and Additional Information <br /> IV I <br /> 15, GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately 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 transport according to applicable international and national governmental regulations. If export shipment and I am the Primary <br /> Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowiedgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if 1 am a large quantity generator) or (b) (ifl am a small quantity generator) is We. <br /> GeneratorslOfferor's Pdntedfryped Name Signature Month Day Year <br /> 16. International Shipments <br /> ❑ Import to U.S. ❑ Export from U.S. Port of entrylexit: <br /> E Transporter signature (for exports only): Date leaving U.S.: <br /> W 17. TransporterAcknowledgment of Receipt of Materials <br /> LU <br /> Transporter 1 PrintedfTyped Name Signature Month Day Year <br /> O <br /> d <br /> Z Transporter 2 PrintedfTyped Name Signature Month Day Year <br /> t- <br /> 18. Discrepancy <br /> 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number: <br /> 18b, Alternate Facility (or Generator) U.S. EPA ID Number <br /> J <br /> v <br /> ua- Facility's Phone: <br /> LL, 18c. Signature of Alternate Facility (or Generator) Month Day Year <br /> a <br /> Z <br /> ILD <br /> 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> 0 1 , 2. 3, 4, <br /> 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Pdntedfryped Name Signature Month Day Year <br /> EPA Form 8700-22 (Rev. #12"17) Previous editions are obsolete. °� ' � �� _ � � � � Vis ) fr f . OT <br />