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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Gerenerator ID Numb2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST Kc <br /> S.Generators Name and Mailing Address Generators 9118 Address(if a Brent than mailing address) v <br /> Generators Phone:. <br /> 6.Tansperter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Faplity Name and Site Address U.S.EPA ID Number <br /> Fadlit(a Phone: <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,lO Number, 10.Containers 11,Total 12.Unit <br /> HM and Packing Group(if any)) No. Typo Quantity WI Not. 13.Waste Codes <br /> ZLIU <br /> 2. <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information. <br /> 1r i" <br /> 15. GENERATOR'SiOFFEROR'S CERTIFICATION:I nereby declare that the cmntentsofthls oansignmentare fully and accurately described above bythe propershipping name,am are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governments!regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contenta of This consignment conform to the terns of the attached EPA Acknowledgment of Consent. <br /> I badly that tae 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. <br /> GermatofsrOderors Pnntad7Typed Name Signature Month Day Year <br /> 24 16.International Shipments — <br /> (— ❑Import to U.S. ❑Export tram US Pan of enbyrekib <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.ThimpoderAckwwledgment of Receipt of Materials <br /> OTransporter 1 Pnntedrr/ped Name Signature Month Day Year <br /> m <br /> Transporter PrintetlrTyped Name Signature Month Day Year <br /> K <br /> 4— <br /> i18.Discrepancy <br /> 18a.Discrepancy Indication Space ElOuandty ElType ElResidue El Partial Rejection ❑Full Rejection <br /> Manifest Reference Number <br /> lab.murnate Facility(or Generator) U.S.EPA IO Number <br /> J <br /> U <br /> LL Facri Phone: <br /> au 18c,Signature ofAltemate Facility for Generator) Monty Day Year <br /> Q <br /> 2 <br /> H19.Hazardous Waste Report Management Method Codes(i.e..codes forhazardous waste treatment,disposal,and recycling systems) <br /> 0 1. 2. <br /> 1 20.Designated Facility Owneror Operator.Certification of receipt of hazardous materials covered by Ne manifest except as noted in Item Ise <br /> Pnntedrryped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous adidons are obsolete. GENERATOR'S INITIAL COPY <br />