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. . <br /> dm <br /> g <br /> P\ease prink or type. Form Approved. OMB No. 2050-0039 <br /> 1GtorlD Number 2 Page 1 of 3 Emergency Response Phone , 4 Manifest Tracking Number <br /> Alf RMNAZARDOUS enersum <br /> WASTEMANIFESi ° <br /> "} <br /> SKS <br /> 5. Generator's Name and Mailing Address. Generators Site Address (if different than mailing address) <br /> .. <br /> Generators Phone: ' <br /> 6. Transportert Company Name , r ,.,, U.S. EPA ID Number ._ <br /> 7. Transporter 2 Company Name U.S. EPA ID Number <br /> I- Ilei <br /> S. Designated Facility Name and Site Address U.S. EPA ID Number <br /> Facility's Phone: <br /> gal 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 , Total 12. Unit 13. Waste Codes <br /> r <br /> HM and Pecking Group (if any)) No. Type Quantity Wt.NoL <br /> -, <br /> cw) <br /> 3 Q <br /> Ile <br /> 2' <br /> Z 2 <br /> Ile %l3 <br /> 4. <br /> ! 14 Special Handling Instructions and Additional Information - <br /> - <br /> r <br /> 15 GENERATORSIOFFEROR'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 Iabeledlplacarded, and are in all respects in proper condition for transport according to applicable interra5onal and national govemmental regulations. If export shipment and I am the Primary <br /> Exporter, I cert fy that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certfy that the waste minimization statement idenfitied in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (ill am a small quantity generator) is We. <br /> GeneratorslOfferors Printed/Typed Name Signature Month Day Year <br /> el <br /> 16 International Shipments <br /> i— ❑ Import to U.S. ❑ Export from U.S. - Port of entrylexit <br /> z Transporter signature (for exports only) Date leaving U.S.: <br /> M 17 Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Pnntedrlyped Name Signature _ Month Day Year <br /> a If f, <br /> "-. ` <br /> Zaai Transporter Pnntedfryped Name Signature Month Day Year <br /> K <br /> r <br /> 18 Discrepancy ,:: <br /> 18a Discrepancy Indication Space ❑ Quantly El Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number. <br /> . 18h Alternate Facility (or Generator) , U.S. EPA ID Number <br /> V <br /> uu. FacilitVDesignated <br /> 's Phone <br /> wSignature of Alternate Facility (or Generator) Month Day Year <br /> : Z Z <br /> S2s Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> ® 2. 3.Faclty Owner or Operator Cer6ficatlon of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Name Signature Month Day Year <br /> EPAForm 8700-22 (Rev 1217) Previous editions are obsolete GENERATOR' S INITIAL COPY <br />