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Please primer type.(Form designed for use on elite(12-pitch)typewriter.) (.' Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS1.Genantor ID Number 2.Pagel of 3._Emergency Reetionse Phone 4.ManNest Tracking Number �/ INASTE MANIFEST J J K 5 Generator's Name and Mailing Address - Generators Site Address(if different lh"gmailing address) Generators Phone: 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA IU Number 8.Designated Facility Name and Site Address / U.S.EPA ID Number Fetiliys Phone: ga 9b.U.S.DOT Descnpbon(including Proper Shipping Name,Hazard Class,10 Number, 10.Containers 11.Total 12.Unit HM and Pecking Group if arty)) No. Type Quantity WWol. 13.Waste Codes a Oa W 1 w t7 3. 14.Special Handling Instructions and Additional Information 15. GENERATOR'SIOFFEROR'S CERTIFICATION: 1 hereby declare that the contents of this consignment are fully and accurately described above by the proper shipleng llama,and are classified.packaged, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable intemationaland national governmental regulations.If export shipment and I am the Primary Exporter,I unity that Bre contents of this consignment conform to the terms of the attached EPAAcilrlmvledgment of Consent. 1 cenity that the waste minlmizaSml statement identified in 40 CFR 262.27(a)(if I am a targe quantity generi or(b)(if I am a small quantity generator)is true. GeneralWs(Oflerors Primed/Typed Name Signature Month Day Year F 16.International Shipments ❑Import to U.S. ❑ _ po Export Imre U.S. Pon of emrylexil: Z Transporter signature(for exports only): Date leaving U.S.: w 17.TrensporterAcknowl"ment of Receipt of Materials Transponer 1 Pnmted.7yped Name Signature Mo�li�l pay. Year a s I N az Transporter 2 PrmtedyTyped Name Signature Month Day Year C 1- i18.Discrepancy IS&Discrepancy indication Space ElQuantity ❑Type ❑Residue ❑PeNal Rejection ❑Full Rejection Manifest Reference Number. 18b.ASemate Facility(or Generation) U.S.EPA IO Number J U norC Faoliys Phone: W 1Sc.Signature ofAftemate Facility(or December) Month Day Year Q 2 a—i t9.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment disposal,and recydtrg systems) 2. 3. 4. 1 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the mandest except as noted in It Ise Punted Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR