8700-22 Uniform Hazardous Waste Manifest

Please print or type. (Form designed for use on elite (12-pitch) typewriter.)

Form Approved. OMB No. 2050-0039

UNIFORM HAZARDOUS 1. Generator ID Number
WASTE MANIFEST

2. Page 1 of 3. Emergency Response Phone

5. Generator's Name and Mailing Address

4. Manifest Tracking Number

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

10. Containers

9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number,
and Packing Group (if any))

No.

Type

11. Total
Quantity

12. Unit
Wt./Vol.

13. Waste Codes

GENERATOR

1.

2.

3.

4.

14. Special Handling Instructions and Additional Information

TR ANSPORTER INT'L

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

■

■ Export from U.S.

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

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

Signature

Month

Day

Year

Signature

Month

Day

Year

18. Discrepancy
18a. Discrepancy Indication Space

■ Quantity

■ Type

■ Residue

■ Partial Rejection

■ Full Rejection

DESIGNATED FACILITY

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

U.S. EPA ID Number

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

Month

Day

Year

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

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

DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED)