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Please print or type. (Form designed for use on elite (12 -pitch) tvvewriter.) <br />Fnrm Annrmind ()MR Nn :nr)n-nnaA <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. { ?r3 <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone 4. <br />WWI eTracking Number <br />t <br />WASTE MANIFEST <br />- <br />-'-7----f--� <br />--{I <br />5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />I <br />Generator's Phone: <br />6. Transporter 1 Company Name U.S. EPA ID Number_w- <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />I <br />8. Designated Facility Name and Site Address U.S. EPA ID Number~- _ —____ <br />Facility's Phone: <br />9a, <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt./Vol. <br />13. Waste Codes <br />No. <br />Type <br />O <br />eu <br />C7 <br />3: <br />4 <br />14. Special Handling Instructions and Additional Information <br />15. GENERATOR'S/OFFEROR'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 i'rimary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />Generator's/Offeror's Printed/Typed Name Signature Month Day Year <br />{ <br />-r <br />F- <br />16. International Shipments <br />❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: <br />Z <br />Transporter signature (for exports only): Date leaving U.S.: <br />W <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Printed/Typed Name '' Signature Month Day Year <br />O <br />CL <br />Z <br />_ <br />Transporter Printed/Typed Name Signature' Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space <br />❑ Quantity ❑Type ❑Residue ❑Partial Rejection El Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />V <br />Facility's Phone: <br />® <br />� <br />18c. Signature of Alternate Facility or Generator ~"��"�`- <br />9 Y ( ) <br />th Day Year <br />Q <br />T <br />Z <br />CD <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) ��-7 <br />0 <br />1. <br />2. <br />3. <br />4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />PrintedrfypedName Signature Month Day Year <br />g / f <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. { ?r3 <br />