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. . Please print or type. <br /> 3 Form Approved. OMB No. 2050-0039 <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2. Page 1 of 3 Emergency Response Phone 14. Manifest Tracking Nu be <br /> WASTE <br /> r ( <br /> ' <br /> 5. Generators Name Mailing Address Generators Ste Address (it different than mailing address) <br /> vi <br /> r <br /> Ge e ato s Phone: _ <br /> 6 Transporter 1 Company Name U.S. EPA ID Number VVV <br /> 7 Transporter 2 Company Name U.S. EPA ID Number <br /> 8 Designated Facility Name and S teAddress , _ <br /> U.S. EPA ID Number <br /> Faclt 's Phone: <br /> ga 9b: U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Centel am 11 . Total 12. Unit 13. Waste Codes <br /> HM and Packing Group (if any)) No. Type Quantity Wt'N01. <br /> 1 <br /> w <br /> Z 2 <br /> w <br /> C7 <br /> 3 <br /> 4 <br /> I <br /> 14. Special Handling Instructions and Additional Information <br /> 11 L 1j I <br /> rt - <br /> 15 GENERATOIR'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 l am the Primary <br /> Exporter I cell that the contents of this consignment conform t0 the terms of the attached EPAAcknowledgment 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 /> Gen rators/Offerors PnniedlTyped Name Signature Month Dey Year F <br /> j 16 International Shipments <br /> F ❑ Import to U.S. El Export from U.S. Pon of entry/exit: <br /> Z. Transporter signature (for exports only): Date leaving U.S.: <br /> . 17 Transporter Acknowledgment of Receipt of Materials111 _ <br /> Tramporter I Pdnted/Typed tame Signature Month Day Year <br /> t „ <br /> Z Transporter 2 PrintedlTyped Name Signature Month Day Year <br /> Q <br /> 16 Discrepancy -. <br /> 11 Discrepancy indicator Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number: <br /> 1116 Alternate Faclity (or Generator) U.S. EPA ID Number <br /> U <br /> ui Faclys Phone <br /> w <br /> 18c. Signature of Alternate Facility (or Generator) Month Day Year <br /> Z ` <br /> 5519. 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 1 Be <br /> PrntedTFyped Name SignatureMonth Day Year <br /> EPA. Form 8700-22. (Rev. 12-17) ;Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />