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- Please print or type. (Form desiqned for use on elite (12 -pitch) typewriter.) Form Approved. OMB No. 2050-0039 EPA Form 8700-22 (Rev. 3-05) Previous editions are obso+ete. UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number WASTE MANIFEST J J K 5. Generators 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 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes No. Type HM and Packing Group (if any)) Quantity Wt.Nol. 1. O w 3. 4. y 14. Special Handling Instructions and Additional Wonoatan 15. GENERATOR'SIOFFEROR'S CERTIFICATION: i hereby declare that the contents of this xrs ^rren1 are t'Jity and accurately described above by the proper shipping name. and are ciassMed, packaged. marked and iatE ea,pzcacded, and are in ati respems in proper condition for transport according to appiicsble international and national governmental regulations. If export shipment and I am the Ptimary Exporter, l cer y that the contents of he consignment confarm to the terms of the attached EPA Admew!edgment of Consent certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if! am a sma4 quantity generator) is true. Generator'slOfferoes Printedryped Name Signature Morar Day Year -j I. 16. International Shipments ❑ Import to U.S. Export from U.S. Port of entrylexit: - Transporter signature (for exports only): Date leaving U.S.: LU 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Cay Near O r1 U) Trarmper;er 2 Prnted,Typed Name Signature Month Day Year F- 18. Discrepancy 18a. Discrepancy Indicabon Spam❑ Quantity � r� ❑ Residue ❑Partial Rejection El Full Rejection Manifest Reference Number. 18b. Alternate Facility (or Generator) U.S. EPA ID Number J U LL Faci!!ty's Phone: w1&. Signature of Alternate Faw!lly (or Generatrl Month Day Year a z 19. Hazardous Waste Recc-':'a a;e-e=a Mle^ ,- :;caes e.. cities for hazardous waste treatment, disposal, and recycling systems) C 1. 2_ 3. 4. 20. Designated Facility Owner or Operayr.-e-tfication of receipt of hazardous materials covered by the manifest except as nded in Item 18a Printed/Typed Name Signature Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obso+ete.