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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) <br /> 1.Generator ID Number Foran Approved.OMB No.2050-0039 <br /> [11: <br /> NIFORM HAZARDOUS 2 Page 1 of 3 Emergency Response Phone =0191Tracking Numb6 4er <br /> ASTE MANIFEST 8 I �[ <br /> ator s(�ameAradMadrngAddress JJ�\GeneratorsSrte Address(if different than mailing address) <br /> rs Phone. ' <br /> 6.Transporter 1 Company Name <br /> U,S.EPA ID Number <br /> 7,Transporter 2 Company Name <br /> U.S.EPA ID Number <br /> 8.Desirgnated and Site Address <br /> U.S.EPA ID Number <br /> A 74 <br /> ?k". <br /> Facility's Phone: <br /> ga, 9b U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 16,Containers <br /> HM and Packing Group(if any)) 11.Total 12.Unit <br /> No. Quantity W1.Nor. 1 Waste Codes <br /> �es <br /> Type <br /> uJ <br /> a 2. <br /> W <br /> C7 <br /> i <br /> 4 3. <br /> ESpecialnstructions and � <br /> 15. GENERATOR'SfOFFEROR'S CERTIFICATION: I hereby declare that the contents of this co0gnment 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 <br /> Exporter,i certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. Primary <br /> I certify that the waste minimization statement identified n 40 CFR 262.27(a)(if I am a Large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> GeneratorslOftercrs'PrtoWTypsd Name Signatu <br /> Month Day Y of <br /> —J16 International Shipments ` <br /> ❑Import to U.S. ❑Export from U.S. Port of entrylexit: <br /> Transporter signature(for exports only)- <br /> bate lea�ng U.S.: <br /> � 17,Transporter Acknowledgment of Receipt of Nfatenals _ <br /> Transporter 1 PrintedlTyped Name ( t Srgnature <br /> �r Month. Day; Year <br /> QTransporter 2Printed)lypedName <br /> F Signature w w Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Perlis[Rejection J ❑Full Rejection <br /> 18b.Alternate FacilityManifest Reference Number: <br /> (or Generator) <br /> � U.S.EPA ID Number <br /> V <br /> Facility's Phone: <br /> IQ 18c.Signature ofAlternate Facility(or Generator) <br /> zMonth Day Year <br /> W19.Hazardous Waste Report Management Method Codes(i.e-codes for hazardous waste treatment,disposal,and recycling systems) <br /> C3 1 2, 3 <br /> 4. <br /> 20.Designated Facility Owner or Operator:Certificat on of receipt of hazardous materials covered by the West except as noted in Bern 16a <br /> PAntedlTyped Name Signature <br /> MonthDay Year <br /> EPA Foran 8700-22(Rev.3.05) Previous editions are obsolete. <br /> GENERATOR'S INITIAL COPY <br />