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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 _701,14783425 4.Manifest Tracking Number WASTE MANIFEST ,1 r -� 8 3 2 5 JJ K 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) Generators 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: ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) No. Type Quantity Wt,NOI. 13.Waste Codes 1 , Q Z 2. W U 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 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 Cronsent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or tti.(ifI am a small quantity generator)is true. GeeratorslOfferors Printedrryped Name Sigpature� Month Day..: ar f <. 16.International Shipments F— ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Transporter signature(for exports only): Date leaving U.S.: w17.Transporter Acknowledgment of Receipt of Materials Transporter 1 PrintedlTyped Name ) ' 1 Signature -- { Mo Day, Year Z Transporter 2 Printedrryped Name Signature-'' Month Day Year Q t- 18.Discrepancy 1 Ba.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: >- 181b.Alternate Facility(or Generator) U.S.EPA ID Number J U LL- Facility's Phone: U0 18c.Signature of Alternate Facility(or Generator) Month Day "ear r-- Q Z 2 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 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 PrintedlTyped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY