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Please print or type.(Form designed for use on elite(12-pitch)*ter.) - Fomn Approved.OMB No.2050-0039 ItIUNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3 Emergency ResJpona Phone 4,Manifest Tracking Number . WASTE MANIFEST - / �'-i//l/ - - ;J J,, .`,R4490 JJK 5.Generators Name and Mailing Address Generator's Stte Address(if different than mailing address) - Generators Phone: - 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter Company Name U.S.EPA ID Number B.Designated Facility Name and Site Address U.S.EPA ID Number Facilitys 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)) 13.Waste Codes No. Type Quantity W1.Nol. o . 00 W Z 2. W I V 3. 4. t.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 latmedlplacarded,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 tens of the attached EPA Acknowledgment of Consent. I codify 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. Generators10Berors Printed(Typed Name Signature Month Day Year —n 16.International Shipments - Z1:1Import to U S. ❑Export from U.S. Port of entrylexit Transporter signature(for exports only): Date leaving U.S.: w 17.TransporterAcknoWedgment of Receipt of Materials OTransporter 1 PrintedRyped Name Signature Month Day Year 1 QTmnspormr2 PrintedrRyped Name Signature Month Day Year C r 18.Discrepancy 18a.Discrepancy Indication Space i ❑ Quanti ty ❑Type Partial Rejection ❑Full Rejection) y'� ry,,Nm F 16b.Altemate Facility(or Generator) U.S.EPA 10 Number v _ MAY0I [dila W Facildys Phone: i&.Signature of Alternate Facility(or Generator) VI1MVJjjNq /�f�E a�T}.( Month Day Year z per-"WSER`IICES Hazardous Waste Report Management Method Codes i.e.,codes for hazardous waste treatment,disposal,� P 9 ( poral,and recycling systems) L 2. 3. 4. L 1 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in hem las Frinted(ryped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY