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Please print or we (Form designed for use on elite(12-pitch)typewriter.) • Form Approved.OMB No.2050.0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page i of 3.Emergency Response Phone 4.Manifest Tracking Number WA�fE MANIFEST ' ;.. �;•f .' .. �� 5.Generators Name and Mailing Address Generators Site Address(d different than mailing address) ;eneretors Phone: -- 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number B.Designated Facility Name and Site Address U.S.EPA ID Number Facility's Phone ! 7 9a 9b.U.S.OOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Pecking Group(ff any)) 13.Waste Codes No. Type Quantity WWoI. L K w 3. i 4. i 14.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 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)(d I am a large quantity generator)or(b)(if I am a small quantity generator)is We. GeneretoesrOherors Pnntedrryped Name Signature - _ Month Day Year —� 16.International Shipments F ❑Import to U.S. ❑Export from U.S. Pat of entry/exit: z TransPodersi nature(for exports only): Dale leaving U.S.: Lid 17.TmnsporterAcknowledgment of Receipt of Materials Transporter 1 Printedr-yped Name Signature Month Day Year pa W 4 Transporter 2 PdntWffyped Name Signature Monty Day Year a F } 18.Discrepancy 18a.Discrepancy Indication Spoto ❑ Quantity ME� E I Vsidue ❑Padial Rejection El Full Rejeceference Number: 18b.Ahemate Facility(or Generator) U.S.EPA ID Number ra FacilVs Phone: w 18c.Signature of Alternate Facility(or Generator) Mill'ittJINMEN I Month Day Year z PERMIT/SEWCES ti19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 1' 2. 3 4. I r20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Prnmedllypad Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY