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ti i ii ii i i ii t i ti►it t��.�;:��►►►it t tt t ii tt Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS GeneratorID Number 2.Page 1 of 3.Emergency Response Phone 4.ManifestTrackin Number WASTE MANIFEST1,1. „ ; 1 004510986 FLE 5.Generator's Name and Mailing Address t, Generator's Site Address(if different than mailing address) Generator's Phone: 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address {, U.S.EPA ID Number t-h i Facility's Phone: 9a, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) 13.Waste Codes No. Type Quantity Wt.Nol. O it QH W ti+ ,; „r- UJ i , 3. 4. 14.,Special Handling Instructions and Additional Information 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, 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 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. 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. Generators Offero s Printed/Typed Name igna ure Month Day Year J 16.International Shipments 1- ❑Import to U.S. ❑Export from U.S. Port_of entry/exit: _ Z Transporter signature for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month ay ear QTransporter 2 Printed/Typed NameSignature Month Day Year H 18.Discrepancy 18a.Discrepancy Indication Space Quantity El Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number _J V a LL Facility's Phone: Lo 18c.Signature of Alternate Facility(or Generator) Month Day Q Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 1. 2. 3. 4. Ll20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Pdnted/Typed Name Signature Month Day Year EPA Fprm 8700-22(Rev.3-05).Previous teditions are ottsolet�, GI~;�ERATOR'3 INITIAL COP .. '” �4 w,k ,;!:/'iii'. 1 �,$ c R tt r :.r f� . i i Y