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Please print or type.(Form designed for use on etite(12-p ypewnter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1 Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST MJJ K tor' 5.Generators Name and Mailing Address Generas Site Address(if different than mailing address) �9 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 HM and Packing Group(if any)) 11.Total 12.Unit 13.Waste Codes 1. No. Type Quantity Wt.Nol. O Z 2. i w 4. r 13 14.Special Handling Instructions and Additional Information 15. GENERATOR'S/OFFEROR'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 smalluanti Generator's/Offeror's Printedffyped Name q ty generator)is true. Signature Month Day Year --r 16.International Shipments Z ❑Import to U.S. ❑Export from U.S. Port of entry/exit: /exit: - Transporter signature(for exports only): ry Date leaving U.S.: LIJ17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed Typed Name p Signature CL Month Day Year Transporter 2 Printed Typed Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection 1 ❑Full Rejection 18b.Alternate Facility Manifest Reference Number: _ ty(or Generator) r U.S.EPA ID Number U Facility's Phone: UJI 18c.Signature of Alternate Facility(or Generator) ZMonth Day Year y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) UJI C1 t. 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-051 Previous editions are obsolete. GENERATOR'S INITIAL COPY