1C-02 Uniform Hazardous Waste Manifest.pdf

Please print or type. Form Approved. OMB No. 2050-0039

UNIFORM HAZARDOUS

WASTE MANIFEST

1. Generator ID

Number

2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number

5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address)

Generator's Phone:

6. Transporter 1 Company Name U.S. EPA ID Number

7. Transporter 2 Company Name U.S. EPA ID Number

8. Designated Facility Name and Site Address 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.

2.

3.

4.

10. Containers No. Type

11. Total Quantity

12. Unit 13. Waste Codes Wt./Vol.

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.

Generator's/Offeror's Printed/Typed Name Signature Month Day Year

16. International Shipments Import to U.S. Export from U.S. Port of entry/exit:

Transporter signature (for exports only): Date leaving U.S.:

17. Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day Year

Transporter 2 Printed/Typed Name Signature Month Day Year

18. Discrepancy

18a. Discrepancy Indication Space Quantity Type

Residue

Partial Rejection

Full Rejection

18b. Alternate Facility (or Generator) Manifest Reference Number:

U.S. EPA ID Number

Facility's Phone:

18c. Signature of Alternate Facility (or Generator) Month Day Year

119. . 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. 12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM

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