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Please pant or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS [Ge,art.,IDN,mber 2.Page 1 of 3.Emergency Response°h ne 4.Manifest Tracking Number WASTE MANIFEST J J K 5.Generators Name and Mailing Address Generator's S*e Address trf different than mailing address) Generator's Phone: 6.Transporter 1 Company Name U.S.EPA ID Number t 7.Transporter 2 Compar;y`Jame 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 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any) No. Type Quantity Wt.Nol. L c O a -- Q Z 2. w c9 3. 4. I 14.Special Handling Ins-icticns and Additional Inforr-ation 15. GENERATOR'SIOFFEROR'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 labelediplacarded,and are in all respects in proper condition for transport according to applicable intemationaland national govemmental 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 EPAAcknovdedgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a targe quantity generator)or(b)(if I am a small quantity generator)is true. Generators/Offerors PrintedlTyped Name Signature Month Day Year J 16.International Shipments Z 1-1Importto U.S. El Export from U.S. Port of entry/exit: Transporter signature(for exports only): Date leavirg U.S.: LW 17.Transporter Acknowledgment of Receipt of Materials Li Transporter 1 PrintedTyped Name Signature Month Day Year O CL co ZZ TfanSDgrter2 Printedr?ypad Name Signature Month Day Year rr f- 18.Discrepancy 18a.Discrepancy Indicator Space7L ^_ Quantity yoe ❑Residue Partial Rejection El Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator U.S.EPA ID Number J U Facility's Phone: W 18c.Signature of Aitema,c Facility(r Generatcr'l Month Day Year Q Z 19.Hazardous Waste Repert Management Method Codes(i.e.,cedes for hazardous waste treatment,disposal,and recycling systems) 1. 2 3 4. 1 20.Designated Facili,C;,,ner or Operator:Certif gaticn of receipt of hazardous materials covered by the manifest except as noted in,Item 18a Printed/Tvped Na-ie Signature Month Day Year EPA Form 8700-22(Rev.3-051 Previous editions are obsolete. ?yER7;': )R'S INITIAL COPY