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Please print or type. (Form designed for use on elite (12 -pitch) tvoewmer.) Form Approved. OMB No. 2050-0039 EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number WASTE MANIFEST J J 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: ga 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. w I i 3. 2014 s JUL2 8 4. E VIRON EIS 1 14. Special Handling Instructions and Additional Information 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'slOfferor's PrintedJyped Name Signature, ; ; ,, Month Day Year .-r16. P- International Shipments ❑ Import to U.S. ❑ Export from U.S. Port of entrylexit: Z Transporter signature (for exports only): Date leaving U.S.: W 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed[Typed Name Signature Month Day Year O QTransporter 2 Printed[Typed Name Signature Month Day Year F 18. Discrepancy 18a. Discrepancy Indication Space ❑ ❑ ❑ ❑ Full Rejection ❑ Quantity Type Residue Partial Rejection I Manifest Reference Number. 18b. Alternate Facility (or Generator) U.S. EPA ID Number J U u Facility's Phone: w 18c. Signature of Alternate Facility For Generator) Month Day Year Q Z CD 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) ul 1. 2. T 4. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Pdrited/Typed Name Signature Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR