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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)
File Type | application/pdf |
File Title | Example Manifest Form |
Subject | sample first page of the new hazardous waste manifest form |
Author | US EPA, Office of Solid Waste |
File Modified | 2016-05-24 |
File Created | 2004-04-13 |