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3 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter) Form Approved.OMB 146c•20 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4 Manifest Tracking Number <br /> WASTE MANIFEST T s <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> r.' :it ,. •; -<A <br /> • <br /> Generator's Phone:::' <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> p.%±'.;r-rr�:at.. _•:s:: . 9Y. _. { <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address:. Y U.S.EPA ID Number <br /> t'='t�i r€;�r,tTf•i°=3',i�$�•t"11:; ..... <br /> .Stt+�:•i; ":ir'°.+;;i``..=.;•::( f,q'I"i.?,,rl}' <br /> 45t'i`;4i <br /> f.3.ri,,.t..5 •+i <br /> Facility's Phone: <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> t <br /> w <br /> W i <br /> i <br /> 3. ; <br /> i <br /> 4. <br /> t ) <br /> 14.Special Handling Instructions andditionai Information _ r <br /> -%}+'�' !�•€%.�-+� %�3�4" �° �"'f€--fit 1,�` �;, _,f�� _ •i f 7:'�$- % �'}-� �y - <br /> r- ,i.<"'.,zit�f`. _ azT .s �._w•!;,-�r� .ii,.. C � - _ <br /> :�I' '_i_.,,.; T -.,.it'- .t AND <br /> 15. GENERATORWOFFEROR'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 EPA Acknowledgment of Consent. <br /> I cerlify�.that the waste minimization statement identified in 40 CFR 26227(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> GeneratoesfOfferoes Printedffyped Name Signature Month Day Year- <br /> f <br /> J 16.International Shipmentsf <br /> f- ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.TransporterAdmowledgment of Receipt of Materials <br /> r ' <br /> Transporter 1 Prinledfryped Name r Signature a f, Month Day Year <br /> I <br /> Z¢ Transporter 2 Printed/Typed Name Signature i I Month Day Year <br /> r3' p• _ <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity ❑Full Re ection <br /> Type Residue Partial Rejection % <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> _J <br /> 0 <br /> I Facility's Phone: <br /> C3 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> 4 <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> w 1• 2. <br /> T - <br /> 20. <br /> Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.0.05) Previous editions are obsolete. <br /> DESIGNATED FACILITY'S COPY <br /> f <br />