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Please print or type. (Form lesioned for use on elite (12 -pitch) typewriter.) Form Approved. ONIB No. 2050-0039 EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DE$IGNATED FACILITY TO GENERATC UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number WASTE MANIFEST — ) JJ K 5. Generator's 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: ya 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. Z 2. THIS WASTE aTRavl l a;s;� +:..'I ;:. . ,( it W FOR RE%i `Y." _ _h F,.- 3. ti �+.) 4 X11-�.'•�*� �t 9 01-F, Ctl1 ' AS 4. ya 0 JU i t 14. Special Handling Instructions and Additional Information ENV! DEPARTMENT 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 Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I, am a small quantity generator) is true. Generator's/Offerors Printed(fyped Name Signature Month Day Year -J H 16. International Shipments' ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: K Transporter signature (for exports only): Date leavng U.S.: W 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 PrintedfTyped Name Signature Month Day Year CL QTransporter 2 Printed/Typed Name Signature Month Day Year t- 18. Discrepancy 18a. Discrepancy Indication Space ❑ quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: 18b. Ntemate Facility (or Generator) U.S. EPA ID Number J_ V Facility's Phone: W 18c. Signature ofNternate Facility (or Generator) Month Day Year Q Z N19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) w 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 ' Printed/f ped Name Signature. Month Day Year : EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DE$IGNATED FACILITY TO GENERATC