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Please prat or lyoe ( Form des:gned for use on elite ( 12-oitch ) typewriter _ i Form Approved , OMB No. 2050-0039 <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2. Page 1 of 3 Emergency Response Phone 4. Manifest Tracking Number FLE <br /> WASTE MANIFEST <br /> Generator's Nanr tnd Mai.ing Alines Generaloes Site Address pt different than mailing address) <br /> i <br /> acrIc Phone <br /> i Tran er 1 :°; �rn ,ar,y gams U S EPA ID Numtar <br /> Tran {oder 2 Cmrpany Name tltl US EPA ID Number <br /> I <br /> 8 Designated Facility Name and Site Address US EPA ID Number <br /> Facility s Phone. <br /> ga, 9b U.S DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10 Containers 11 Total 12 Unit 13 Waste Codes <br /> HM and Packing Group (if any)) No Type Quantity Wt Not <br /> O <br /> z 2 <br /> LU <br /> t9 <br /> 3 <br /> f \ <br /> d Slr d al Han&inn lnoiu fc �s and Addil nA infermahor7 <br /> I <br /> 15, GENERATOR'SIOFFEROR'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 Primary <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 he. <br /> Generators/Ofleror's Printeafiyped Name Signature on ayear <br /> 16 International Shipments <br /> t— ❑ Import to U S ❑ Export from U S Port of entrylexit: <br /> z <br /> — Transporter signature (for exports only): Date leaving U .S <br /> LU 17 Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 PrintedfTyped Name SignatuFF Month Day ( Year <br /> ric <br /> O ( I I <br /> n. <br /> QTransporter 2 Printed/Typed Name Signature Month Day Year <br /> a <br /> F . <br /> 18 Discrepancy <br /> 18a Discrepancy Indication Space ❑ Quantity ❑ yp ) j T e ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number: <br /> 18b Alternate Facility (or Generator) US EPA ID Number <br /> _J <br /> V <br /> LL Facility's Phone: <br /> W 18c Signature of Alternate Facility (or Generator) Month Day Year <br /> Q <br /> Z <br /> 19 Hazardous Waste Report Management Method Codes (i e , codes for hazardous waste treatment, disposal, and recycling systems) <br /> { 2 3 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 /> P +nb dTy�rd Name 3igrature Month Day Year <br /> EPA Form 8700-22 ( Rev 3-05 ) Previous editions are obsolete . GENERATOR'S INITIAL COPY <br />