Please print or type. (Form designed for use on elite (12-pitch) typewriter.) UNIFORM HAZARDOUS 1. Generator ID Number WASTE MANIFEST
5. Generator's Name and Mailing Address 2. Page 1 of 3. Emergency Response Phone

Form Approved. OMB No. 2050-0039
4. Manifest Tracking Number

PSC
Generator's Site Address (if different than mailing address)

Generator's Phone: 6. Transporter 1 Company Name 7. Transporter 2 Company Name 8. Designated Facility Name and Site Address

U.S. EPA ID Number U.S. EPA ID Number U.S. EPA ID Number

Facility's Phone: 9a. HM 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, and Packing Group (if any)) 1. 10. Containers No. Type 11. Total Quantity 12. Unit Wt./Vol. 13. Waste Codes

GENERATOR

2.

3.

4.

14. Special Handling Instructions and Additional Information

15. GENERATOR’S/OFFEROR’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, 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 I am the Primary Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. 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. Signature Month Day Year Generator's/Offeror's Printed/Typed Name 16. International Shipments

TR ANSPORTER INT'L

Import to U.S. Transporter signature (for exports only): 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Transporter 2 Printed/Typed Name

I

I Export from U.S.
Signature Signature

Port of entry/exit: _________________________________________________________ Date leaving U.S.: Month Month Day Day Year Year

18. Discrepancy 18a. Discrepancy Indication Space

I Quantity

I Type

I Residue
Manifest Reference Number:

I Partial Rejection
U.S. EPA ID Number

I Full Rejection

DESIGNATED FACILITY

18b. Alternate Facility (or Generator)

Facility's Phone: 18c. Signature of Alternate Facility (or Generator)

Month

Day

Year

1. 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 1. 2. 3. 4.

20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature

Month

Day

Year

EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete.

DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED)