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UNIFORM HAZARDOUS
WASTE MANIFEST
1.GeneratorIDNumber ertcyResponsePhone 4.ManifestTracking Number
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5.Generator's NameandMailing Address Generator's SiteAddress (if different thanmailing address)
Generator'sPhone:
6.Transporter 1Company Name
7.Transporter2CompanyName
8.Designated Facility Name andSiteAddress
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15.GENERKTOR'S/OFFEROR'S CERTIFlCATtON:Ihereby declare thatthecontents ofthisconsignment arefully andaccurately describedabovebytheproper shipping name,andareclassified,packaged,
markedand labeled/placarded,andareinall respectsinpropercondition.fortransport according toapplicable internationalandnational governmental regulations.Ifexport shipment andIamthePrimary
Exporter,Icertify thatthecontents ofthis consignment conform totheterms oftheattached EPAAcknowledgmentofConsent a *
Icertifythatthe waste minimization statement identifiedin40CFR 262.27(a)(if Iam alarge quantity generator)or(b)(ifIam asmall quantity generator)istrue.
Generator's/Offerer's Printed/Typed Name
16.International Shipments I I.•l_lImport toU.S.
Transportersignature (for exportsonly):
17.TransporterAcknowledgment ofReceiptofMaterials
18b.Alternate Facility(orGenerator)
Facility'sPhone:
18c.Signature ofAlternate Facility (orGenerator)
•Exportfrom U.S.Portofentry/exit:
Dateleaving U.S.:
Residue I IPartial Rejection
Manifest Reference Number
U.S. EPA ID Number
19.Hazardous Waste Report Management Method Codes(i.e.,codesforhazardous wastetreatment,disposal,andrecycling systems)
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;notedinesignatedFacilityOwherorlOperatorCertificationofreceiptofhazardousmaterialscoveredbythemanifestexceptasnotedinlten/1
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Month Day Year
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Month Day Year
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Month Day Year
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35.Discrepancy
36.Hazardous Waste ReportManagement Method Codes (i.e.,codes for hazardous waste treatment,disposal,and recycling systems)
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GENERATOR'S INITIAL COPY
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14.Special Handling InstructionsandAdditional InformationJ
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15.GENERATOR'S/OFFEROR'S CERTIFICATION:Iherebydeclarethatthecontentsofthisconsignment arefully andaccuratelydescribed abovebythepropershipping name,andareclassified,packaged,
marked andlabeled/placarded,andareinailrespectsinpropercondition for transport according toapplicable internationalandnationalgovernmental regulations.Ifexport shipmentandIam tiiePriiwy .
Exporter,!cei%tfoaltfteoonter^1certify that the waste minimization statement Identified in 40 CFR262.27(a)(if Iam alarge quantity generator)p;(b)(ifIam asmall quantitygenerator)Is true.
lerator's/pfferqr'sPrinted/Typed Name /
16.InternationalShipments r~n.I IImporttoU.S.
Transporter signature (forexportsonly):
17.
Transporter 1Printed/Typed Name
Transporter2Printed/Typed Name
18.Discrepancy
18a.Discrepancy IndicationSpace P"]Qijantitv
I IExportfrom U.S.Port ofentry/exit
Dateleaving U.S.:
•Type •Residue
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•Partial Rejection
Month Day Year
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Month Day Year
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Month Day Year
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19.Hazardous WasteReportManagement Method Codes(i.e.,codesforhazardouswastetreatment,disposal,andrecycling systems)
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Prtntedflyped Name
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U.S. EPA ID Number26.Transporter Company Name
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Prints5
DESIGNATED FACILITYTO GENERATOR