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Plonza nrint nr tuna [Pnrm r1ocinnorl fnr imp nn Plitp 11*1 tx1nPwritP.r) a Form ADoroved. OMB No. 2050 -0039 EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete UNIFORM HAZARDOUS . 1Generator ID Number 2. Page 1 ofTTIE—m7egency Response Phone J4. Manifest Tracking Number WASTE MANIFEST 1 FLE 5. Generators Name and Mailing Address Generator's Site Address (it different than mailing address) Generator's Phone: 6. Transporter 1 Company Name U.S. EPA ID Number 1V 7. Transporter 2 Company Name U.S. EPA ID Number 8 lily ily Name and Site Address U.S. EPA ID Number .sign _Jated Facility's Phone: 9a. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, 10 Number, 10. Containers 11. Total 12. Unit 13. Waste Codes No. Type HM and Packing Group (if any)) Quantity Wt.Nol. 7 - Js+}.,;`s+}.,;`: , F 77 L 7 -7 I 0 UJI Z 2. 3. 4. 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 small quantity generator) is true. Yenerators/Offerors Printed/Typed Name Signature "I on Day Year —J I— 16. International Shipments D Import to U.S. El Export from U.S. Port of entri/exit: Transporter signature for exports only): Date leaving U.S.: UM 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day Year 0 —Day ZTransporter 2 Printed/Typed Name Signature Month Year18. Discrepancy Discrepancy Indication Space ❑ Quantity F-1 TypeD Residue ElPartial Rejection Full Rejection I18a. Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number Facility's Phone: Lu 18c. Signature of Alternate Facility (or Generator) Month Day Year Z 0 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment disposal, and recycling systems) 1 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 PrintedlTyped !dame Signatufe Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete