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Please print or type. (Form designed for use on elite (12-pitch) typewriter. Form Aoproved. OMB No. 2050-0039 4 GENERATOR UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number <br />JJK <br />Generator's Name and Mailing Address Generators Site Address (if different than mating address) <br />Generator's Phone: I <br />Transporter 1 Company Name U.S. EPA ID Number <br />I <br />Transporter 2 Company Name U.S. EPA ID Number <br />I <br />Designated Facility Name and Site Address U.S. EPA ID Number <br />Facility's Phone: I <br />9a, Pb. U.S. DOT Descnption (including Proper Shipping Name, Hazard Class, ID Number. 10. Containers 11. Total 12. Unit Waste Codes Ft, and Packing Group (if anyi)13. <br />No. Type Quantity Wt.Nol. <br />1 i <br />1 _ <br />2. <br />1,- <br />3. <br />_ <br />4, <br />.1_ <br />1 <br />14. Special Handling Instructions and Additional Information <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 labeied/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 true. <br />Generator's/Offerors Printed/Typed Name Signature Month Day Year <br />I 1 I I <br />-I <br />F— <br />F— <br />16. International Shpments LI Import to U.S. Export from U.S. Port of entry/exit: <br />Transporter signature (for exports only): Date leaving U.S.: TRANSPORTER 17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Printed/Typed Name Signature Month Day Year <br />I I I <br />Transporter 2 Printed/Typed Name Signature Month Day Year <br />I I I I DESIGNATED FACILITY 18. Discrepancy <br />Discrepancy Indication Space Quantity LI Type LI Residue LI Partial Rejection LI Full Rejection <br />Manifest Reference Number: <br />Alternate Facility (or Generator) U.S. EPA ID Number <br />Facility's Phone: I <br />Signature of Alternate Facility (or Generator). . . <br />Month Day Year <br />I I <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 />Printed/Typed Name Signature Month Day Year <br />I I I I <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERA