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• <br /> Form Approved.OMB No.2050-0039 <br /> Ile Q (12pitch)typewriter.) <br /> a Phone 4.Manifest king Number <br /> print or j�e.(Form designed for use on elite <br /> rator ID Number 2.Page I of 3.Emergency Response <br /> UNIFORM HAZARDOUS "�ene <br /> WASTE MANIFEST EST <br /> 5.Generator's Name and Mailing Address Generators Site Address(it different than mailing address) <br /> wits:, <br /> R. <br /> Generators Phone: U.S.EPA ID Number <br /> 6.Transporter 1 Company Name, <br /> CF <br /> U.S.EPA ID Number <br /> 7.Transporter 2 Company Name <br /> U.S.EPA ID Number <br /> B.Designated a and Site Address • _01 <br /> j <br /> K. <br /> q <br /> Facility's Phone, Total: <br /> _:Quantity <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> EN No. Type Quantity Wt./Vol. <br /> H M and Packing Group(if any)) <br /> 101 <br /> 0 <br /> UJI <br /> 2� <br /> Z '6 <br /> -4 <br /> LU <br /> _J <br /> T Y <br /> A <br /> 4. <br /> 14.Special Handling Instructions and Additonal Informationfu <br /> h';"-L declare that re fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> L <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATIO I hereby at the contents of this consignment a d <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)(I I am a small quantity generator)is true. Month Day Year <br /> Generatoestofferoes Printed/Ty ad Name signature <br /> 16-InternationalShipmentsof entry/e <br /> El Import to U.S. 0 Export from U.S. Port le <br /> Date leaving xit: <br /> U.S.: <br /> Z Transporter signature(for exports only): <br /> UW 17 Transporter Acknowledgment of Receipt of Materials <br /> Mon Signature MRY <br /> Ta-risoFier-1 Printo/Typed Name 71 <br /> 0 <br /> Signature Month Day Year <br /> Twansporter 2 Printedrryped Name <br /> ❑I 18.Discrepancy Full Rejection18a.Discrepancy Indication Space Quantity El Type El Residue ❑Partial Rejection <br /> Manifest Reference Number: U.S.EPA 10 Number <br /> 18b.Alternate Facility(or Generator) <br /> ua Facility's Phone: Month Day Year <br /> W18c.Signature of Alternate Facility(or Generator) <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 3• 4. <br /> ® <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Month Day Year <br /> Printed/Typed Name Signature <br /> I]!! I- <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S <br /> INITIAL COPY <br />