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A <br />Please print or type. (Form desi ned for use on elite (12-Ditch ERATOR o. I UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone <br />. %AI 1 e MI/F1 VIMU. VW1C1 IIV. ClialiA.L3 <br />4. Manifest Tracking Number <br />JJK 5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />Generator's Phone: I 6 Transporter 1 Company Name U.S. EPA ID Number <br />I Transporter 2 Company Name U.S. EPA ID Number <br />I Designated Facility Name and Site Address U.S. EPA ID Number <br />Fealty's Phone: I <br />ga. Pb. U.S. DOT Description (inducing Proper Shipping Name, Hazard Class. ID Number, 10. Containers 11, Total 12. Unit HM and Paclting Group (if any(l No. Type Quantity Wt.Not. 13. Waste Codes <br />1. <br />I <br />—4- 4 GENI 2. <br />' <br />3. <br />4. <br />_ <br />Special Handling Instructions and Additional Information <br />GENERATORS/OFFERORS CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name. art are classified, packaged, <br />marked and labelediplacarded. and are in all respects in proper condition for transport accoroing 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(51 (if I am a large quantity generator) or rb) Off am a small quantity generator) is true. <br />Generator'slOfferors Printed/Typed Name Signature Month Day Year 1 <br />-r.' I I I I <br />—..1 <br />F— <br />K <br />International Shipments <br />Import to U.S. Export from U.S. Port of entry/exit: <br />Transporter signature (for exports only): Date leaving U.S.: ...._ TRANSPORTER Transporter Acknow:edgment of Receipt of Materials <br />Transporter I Printed/Typed Name Signature Month Day Year <br />I .1 I <br />Transporter 2 Printed/Typed Name Signature Month Day Year <br />I I I I DESIGNATED FACILITY Discrepancy <br />18a, Discrepancy Indication Space LI 0 Quantity Type Residue Partial Rejection Full Rejection <br />Manifest Reference Number <br />18b. Atemate Facility (or Generator) U.S. EPA ID Number <br />Facility's Phone: I <br />lac. Signature of Alternate Facility tor Generator) Month Day Year <br />I I <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment. cll.:pew* and recycling systems) ' <br />i 2. 3. 4. <br />Designated Facility Owner or Operator: Certification of receipt of hazardous materials coveted by the manifest except as acted in Item 18a <br />Printed/Typed Name Signature Morth Day Year <br />I I 1 I <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR