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Please print or type.(Form designed for use on elite(12-pitch)typewrites) Form Apprdved.OMB No.2050-0039 } UNIFORM HAZARDOU$ 1,Genera}tor ID Number l 2.Page 1 of 3 Emergency Response Phone 4.Manifest Tracking Number y WASTE MANIFEST+ C—.v4�'i�C.CS . ='1 t -i..., .>�,i. r, '. 71 JJI� 5.Generators Name and Mai lin Address Generator's Site Address if di8ereatthan mailing address) r Generators Phone: 6.Transporter 1 Company Nam U.S.EPA ID Number 7.Transporter Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number Facili 's Phone: ga 91b.U.S.DOT Desaiplion(Including Proper Shipping Name,Hazard Class,10 Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(gani No. Type Quantity Wt.Nol. 1. w01 z 2. W 3. 4. 14.Special Handling Instructions and Additional Information e 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are dassified,packaged, marked and Iabeledlplacarded,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 tonna of the attached EPAAcknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 261(if I am a large quantity generator)or(b)if am a small quantity generator)is true. Generators101fera's PrintedRyped Name Signature - Month Day Year h j16.International Shipments F ❑Import to U.S. ❑Export from U.S. Port of entry/edb Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Trans der 1 Printecirryped Name r ! Signature Month Day Year z Transporter 2 Pnnted?yped Name Signature Month Day Year IX r 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number r 18b.Alternate Facility(a Generator) U.S.EPA ID Number 7 U rai Facility's Phone: 18c.Signature of Alternate Facility(or Generator) Month Day Year zz N19.Hazardous Waste Report Management Method Codes Ile.,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 1 Pnnted?yped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY