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Please print or type.(Form designed for use on elite(,2-pitch)typewriter.; Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Nember �Pagef 3Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST _ �� <br /> 5.Generator's Name and Mailing Address Generators-5 le Address(if different than mailing address) <br /> Generators Phone: <br /> 6.Transporter 1 Company NameU.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated FaciRy Name and Site Address, U.S.EPA ID Number <br /> Facility's Phone: <br /> ga, 9b.U.S.DOT Desaiplicn(including Proper Shipping Name,hazard Class,ID Number, 10.Containers 11.Total 12.Ural <br /> 1. <br /> HM and Pacidrg Grcup if any)} Quantity Wt13.Wasle Codes <br /> No. Type Nol. <br /> 11 <br /> O <br /> 2. <br /> LU <br /> 3. I <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the propershipping 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 EPAAcknowledgment of Consent <br /> I cenify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)[f I am a small quantity generator)is hue. <br /> GeneratorslOfferoes Pririted/Typed Name Signature- Mo. <br /> Day Year <br /> -a 16.International Shipments <br /> f ❑Import to U.S, <br /> Z Transporter signature(for exports only): Export from U.S. Port of a _ <br /> Date leaving ng U.S.:U <br /> W <br /> 11.TransporterAckncwledgment of Receipt of Materials <br /> Transporter'PrinletlrTyped,Name Signature Month Day Year <br /> - •l'= ice, -. +li .__ "••.' <br /> a Transporter 2 Printed/Tiped Name Sigralrire r <br /> Month Day Year <br /> 16.Discrepancy <br /> 18a.Discrepancy Indication Space ❑Q.n fity ❑ <br /> Type ❑Residue ❑Partial Rejection El Full Rejecticn <br /> Manifest Reference Number. <br /> 18b.Ailemate Facility(or Generator) U.S.EPA ID Number <br /> ..r <br /> V <br /> Facility's Phone: <br /> 18c.Signature of Alternate Facility or Generator) M.onlh Day Year <br /> Q <br /> Z <br /> W19.Hazardous Waste Report Management Method Codes(.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1' 2• 3. <br /> 4. <br /> 20.Designated Facliily Owner or Operator.Certification of receipt of hazardous rrmtedals covered by the manifest except as noted in Item 18a <br /> Print, <br /> Name Signature Month Day Year <br /> EPA Form 87.00-22(Rev.3-05) Previous editions dre obsolete. + <br /> DESIGNATED FACILITY'S COPY <br />