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<br />Form Approved. OMB No. 2050-0039
<br />EPA Form 8700-22 Rev. 12-17 Previous editions are. obsolete,
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<br />GENERATOR'S INITIAL COPY
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<br />UNIFORM HAZARDOUS
<br />1. Generator ID Number
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<br />2. Page 99 of
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<br />3, me e� Re p�s e P}},�
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<br />4. Manifest Tracking Number pp
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<br />WASTE MANIFEST
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<br />5. Generator's Name and Mailing Address Generators Site Address (if different than mailing address)-
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<br />Generators Phone:
<br />6. Tr�gppderlY mp-apy� � ��,.�,��� r �� U.S. EPA ID Number .� j� i������ 1 ��C�
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<br />7. TransHHptto''rt��e�yr
<br />ComtpSatoy Name U.S. EPA ID Number
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<br />8. Designated Facility Name and Site Address ° (��� �� W(��jj[j?j�c�^ ;3�t� .31:11" U.S. EPA ID Number
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<br />Facility's Phone:
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<br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number,
<br />10. Containers
<br />11. Total
<br />12. Unit
<br />13• Waste Codes
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<br />and Packing Group (if any))
<br />No.
<br />Type
<br />Quantity
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<br />14. Special Handling Instructions and Additional Information '���� : ��' �'•.���R'I�r� .i ���,���,�
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<br />15. GENERATOR'SIOFFEROR'SCERTIFICATION: Thereby 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 tetms of the attached EPAAcknowledgment of Consent. ,�
<br />I certify that the �yaste minimization statement identified in 40 CFR 2fi2.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity eneratorJls true.
<br />Gen1jjey'ratorsSlPy�ff`�`?e}r'ors Printed(fyped Na�mpe Signaiure , r � �^ Month DaY Yea))r
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<br />16.'International Shipments :r
<br />❑ Impart to U.S.. -,, ; ❑Export from U.S. Port of entrylexit:
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<br />Transporter signature (for exports only): Date leaving U.S.:
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<br />17. TransporterAcknowledgment of Receipt of Matenals
<br />TransRorfer'1 PrintedlTyped.Name Signature-'�p � " � Month �y Year
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<br />2 Printe Ifyped Name Signature ( Month Day Year
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<br />18. Discrepancy
<br />18a. Disaepancy Indication Space ❑Quantity ,' ❑Type ❑Residue ❑ Partial Rejection ❑Full Rejection
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<br />Manifest Reference Number: �
<br />18b. Alternate Facility (or Generator) U.S. EPA ID Number
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<br />Facility's Phone:
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<br />18c. Signature ofAlternate Facility (or Generator)
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<br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste Ueatment, disposal, and recycling systems)
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<br />20. Designated Facility Owner or Operator: Cerfificafion of receipt of hazardous materials covered by the manifest except as noted in Item 18a
<br />PrintedlTyped Name � Signature Month Day Year
<br />EPA Form 8700-22 Rev. 12-17 Previous editions are. obsolete,
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<br />GENERATOR'S INITIAL COPY
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