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V/ oioaaa print or lupe. (Form designed for use on elite (12 -pitch) typewriter.) Form Approved. OMB No. 2050-0039 EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DFgarNATFD FA�`I� 9TY TO QENER ATQR UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number JJ WASTE MANIFEST 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: , 9a 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./Vol. '�-- , Z 2• RE(JENE — 3. UL �o 4. ENVIR NME TAL,HEA fH TMENI J PA 14. Special Handling Instructions and Additional Information _ rr. 15. GEN ERATOR'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/Offeror's Printed/Typed Name Signature , r. Month Day Year -ZT 16. International Shipments 11Import to U.S. ❑ Export from U.S. Port of entrylexit: F, z Transporter signature (for exports only): Date leaving U.S.: W 17. Transporter Acknowledgment of Receipt of Materials LLI Transporter 1 Printed/Typed Name Signature Month Day Year Z Transporter 2 Pnnted/Typed Name Signature Month Day Year Q h- 18. Discrepancy 18a. Discrepancy Indication Space ❑ quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: Fes-, 18b. Alternate Facility (or Generator) U.S. EPA ID Number J L) I Facility's Phone: C1 18c. Signature of Alternate Facility (or Generator) Month Day Year t -- Q Z y19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) C1 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/Typed Name Signature Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DFgarNATFD FA�`I� 9TY TO QENER ATQR