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Pie elpntlt or type.(Form designed for use on elite(12-pitch)typewriter.) 1.Generator ID Number Form Approved,OMB No.2050-0039 UNIFORM HAZARDOUS 2.Page 1 of 3.Emergency Response Phone 4.Mar Tracking Number WASTE MANIFEST QiT 3 JJ K 5.Generato s Name and Mailing Address +Generator's Site Address(if different than mailing address) Generators Phone: 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 9 Designated Facility Name and Site Address U.S.EPA ID Number Facili '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 1. No. Type Quantity Wt.Nol. 13.Waste Codes O / Q . w Z 2. UJ 0 3. 4. 14,Special Handling Instructions and Additional Information 15. GENERATOR'SIGFFEROR'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 Iabeled1placarded,and are in all respects in proper condition for transport according to applicable intemabonal 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)(f I am a large quantity genera or(b)('d 1 am a small quantity generator)Is true. GenergiorslOffe rmt ?yped NaSiyrfature F16.International Shipments Z ElImport to U.S. ❑Export from U.S. Port of entrylexit Transporter signature(tor exports only): Date leaving U.S.: w 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Nam - Signature 9 1 <" Mo Day Year a. QTransporter 2Printed/TypedName "'S' Month Day y Year I- 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Re ectia^ 1 Bb.Altemate Facility(or Generator) Manifest Reference Number: U.S.EPA ID Number U uai. Facility's Phone: w 1 Bc.Signature of Alternate facility(or Generator) Month Day a Z W19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) D 1 2. 3. 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printedfryped Name Signature Month Day Year EPA Form 8700-22(Rev.3.05) Previous editions are obsolete. GENERATOR'S INITIAL COPY