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Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) <br />UNIFORM HAZARDOUS WASTE MANIFEST 121. Generator ID Number 22. Page <br />(Continuation Sheet) ? , . <br />Form Approved. OMB No. 2050-0039 <br />23. Manifest Tracking Number <br />^ 1. rF?, ) <br />24. Generator's Name ..--- <br />(o`tJ � <br />- <br />25. Transporter Company Name <br />U.S. EPA 10 Number <br />26. Transporter _...... Company Name <br />U.S EPA 10 Number <br />27a. <br />HM <br />27b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />and Packing Group (if any)) <br />28. Containers <br />29. Total <br />Quantity <br />30. Unit <br />Wt.Nol. <br />31. Waste Codes <br />No. <br />Type <br />cc <br />O <br />W <br />Z <br />W <br />r'7 <br />I <br />32. Special Handling Instructions and Additional Information <br />33. Transporter Acknowledgment of Receipt of Materials <br />LLJ <br />O <br />a <br />Pnnted/Typed Name Signature <br />Month Day Year <br />Z <br />34. Transporter AcknowlecIgment of Receipt of Materials <br />Pnnledrryped Name Signature <br />Month Day Year <br />J <br />U <br />Ll <br />O <br />W <br />35. Discrepancy <br />rn <br />36. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />W <br />D <br />EPA Form 8700-22A (Rev. 3-05) Previous editions are obsolete. <br />DESIGNATED FACILITY TO GENERATOR <br />