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Please print or type. Form Approved.OMR No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST - - - - BF <br /> 5.Gen erator's Name and Mailing Address Generator's Site Address(if different than mailing address) GG,+ <br /> Generators Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address - U.S.EPA ID Number <br /> Facility's Phone: <br /> 9a, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 16.Containers 11.Total 12.Unit 13.Waste Codas <br /> HM and Padding Group if any)) <br /> Na. Type Quantity Wl.Nol. <br /> 1. <br /> K <br /> a <br /> w <br /> z 2. <br /> w <br /> CD <br /> 3. <br /> 4. <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 labeledlplacerded,and are in all respects In proper condition for transport according to applicable International and national governmental regulations.If exportshipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the allached EPAAcknowledgment of Consent. <br /> I cer ffy 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 /> GeneratorslOfferors Printed/Typed Name Signature Month Day Year <br /> 1 <br /> J 16.International Shipments <br /> F— ❑Import to U.S, ❑Export from U.S. Pon of entry/exit: <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.TransponerAcknoWedgment of Receipt of Materials <br /> Transporter 1 Printedrryped Name Signature - - Month Day Year <br /> O <br /> Z Transporter 2 Printed/Typed Name Signature Month Day Year <br /> f- <br /> A. 18.Discrepancy <br /> 18a,Discrepancy Indication Space ❑Partal Rejection <br /> ❑ Quantity ❑Type ❑Residue I ❑Full Rejection <br /> Manifest Reference Number: <br /> 1 Bb.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facilitys Phone: <br /> w 1Be.Signature of Alternate Facility(or Generator) Month Day Year <br /> Z <br /> h19.Hazardous Waste Report Management Method Codes(Ie,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. 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 /> PrintedrTyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />