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-Please print or type.(Form designed for use on elite(12-pi typewriter.) Form Approved.OMB No.2050-0039 TUNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergen)Response Phone 4 Manifest Tracking Number _ WASTE MANIFEST t Orr J(.�- —t J J K 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) VC . Generators Phone: 6.Transporter i 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 Faciligh Phone: gra 91d.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers rot.Total 12.Unit HM and Packing Group(if any)) No. Type quantity WtNot. 13.Waste Codes 1. K Oa o: z . 2 3. 4 4.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 IabeleNplacarded,and are in all respects in proper condifion 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 caMorm to the tens 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. Geneators/Offero's Printsal ed Name Signature Month Day Year 16.International Shipments t— ❑Import to U.S. ❑Expert from U.S Pan of entrylexit Transporter signature(for exports only): Date leaving U.S.: w 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 PdntedlTyped Name Signature Month Day Year O n Q Transponer2 PrintedlTyped Name Signature Month Day Year K r ♦ 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type y ❑Residue ❑Padial Rejection ❑Full Rejection Manifest Referen Fi 18b.Alternate Facility(or Generator) Mt U l]L.nN,i Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year - Q z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treaunent,disposal,and recycling systeri r T}{ 2. 3. 20.Designated Facility Omer or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item the Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY