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Ple.aso.print or type.(Form designed for use on,lite l(12-pitch)typewriter.) Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS1.Generator ID Number Page 3.Emergency Response Phone 1. IManifest Tracking Number <br /> WASTE MANIFESTlr; <br /> 5,Generators Nai a and Mailing Adores 'l 8 V 0 FLE <br /> Generators Site dr6is(if different than I' <br /> malting address) <br /> Gonerator's Phone: <br /> 67angporter I Company Name U,S.EPA ID Number <br /> 7,TGsporler 2 Company Name <br /> U.S,EPA ID Number <br /> 8.Desl9hatedF'a' fty Name and Site Address <br /> U.S,EPA ID Number <br /> Faellity's Phone: ...... <br /> 98. 9b,U.S.DOT Description(including Prope,Shl ping Name,Hazard Class,ID Number, 10.Containers 11,Total 12.Unit <br /> HIM and Packing Group(if any)) 13.Waste Codes <br /> No, Type Quantity WUVoL <br /> Ole, <br /> Z Z <br /> 4, <br /> 14.8pecial Handling Instructions andAdditional Int c r(nalion <br /> J"' <br /> ICATIO 4 <br /> I 'jibby dbabro 197=d"'Vor"ll seribU4 abod bythapro�TMpping name,and are CIA Ified,packaged,71� <br /> marked and labeled/placarded;and are in all ri spec stn proper condition for transport according to applicable international and national governmental regulations,If export shipment and I am the Primary <br /> Exporter,I Codify that the contents of this consl jrim nt conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I coq1ty that the waste minimization statement 1 ankled In 40 CFR 262.27(a)(if I am a large quantity generator)Cr(b)(if I arra smell quanlityllonerator)is tr(a', <br /> JJ.Generators loffefors Prin --------- <br /> me Nam Signature <br /> Month Day year <br /> %J <br /> i(i,international Shipments ! <br /> n Import R U.S. Export from U'S. Port of entry exit: <br /> Z Transporter signature for exports only): <br /> Onto leaving U.S.: <br /> Q� 17.TtensporterAcknowledpont of Receipt of Materli Is <br /> LU <br /> TranspotjoC I Printedfryped Ngrue Signature Month ayear0 <br /> CIL <br /> U) <br /> Z Transporter 2 Printedfryped Name <br /> Signature 4onth —Da—y---Year <br /> 18.Discrepancy <br /> lfla.Discrepancy Indication Space <br /> F] Quantity FITYPS, El Partial Rejection Full Rejection <br /> El Residue <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) <br /> U.S.EPA ID Number <br /> Facility's Phone: <br /> L-1 18c,Signature ofAlternaie Facility(&G—aneralor) <br /> LU Month Day Year <br /> 19,Hazardous Waste Report Management Method des(Le.,codes for hazardous waste.treatment,disposal,and recycling systems) <br /> �4 <br /> 20.Designated Facility Owner or Operator:CerlIfloatio i of r ceipt of hazardous materials covered by(he manifest except as noted In Item 18a <br /> PrinledfTyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions or ob!elate, <br /> GENERATOR'S INITIAL]COPY <br />