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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 2.Page 1 of 3.Emergency Response Phone 4,Manifest Tract ing Number WASTE MANIFEST J J i 5.Generators Name and Mailing Address Generator's Site Address(if different than ma:ling address) Generator's Phone: 6.Transporter 1 Company Name U.S-EPA ID%mbir ' 7.Transporter 2 Company Name U.S.EPA ID Number ' 8.Designated Facility Name and Site Address U.S.EPA ID Number Facl:ty's Phone: ' ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,10 Number, 10.Containers 11,Total 12 Unit FIM and Packing Group(it any)) No. Type Quantity Wt Nol. 13.Waste Codes 1. tY O Z 2. LLJ I 3. ' 14.Special Handling instructions and Additional Information ' 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shippin I name,and are classified,packaged, marked and Iabeiedlplacarded,and are in ali respects in proper cordtion for transport according to applicable international and national governmental regulations.If ex)ort 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)(9 am a large quantity generator)or(b)(it I am a small quantity generator)is true. ' Generator'sOfferor's PrintediTyped Name Signature Month Day Year 16.International Shipments F— El Impor to U.S. Export from U.S. Port of entrylexi:: _ ' Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment cf Receipt of Materials Transporter 1 PrintedrTyped Name Signature Month Day Year O Transporter 2 PrintedlTyped Name Signature Month Day Year F�- 18.Discrepancy ' i8a.Discrepancy Indication Space Quen6ty, ❑Type ❑Residue ❑Parial Rejectio:m U Ful Rejection Manifest Reference Number: 18b.Alternate Facility(or Generatar) U.S.EPA 10 Numb?r ' J U uQ Facility's Phone: W 18c Signature of Alternate Facility(kr Generator, Moeth Day Year Q Z y19.Hazardous Waste Report Management frlethxl Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) G i. 2 3. 4. ' 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in IOem 18a arintedffyped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY 1