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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No 2050-0039 UNIFORM HAZARDOUS 1 1.Generator ID Number 2 Page 1 of 3.Emergency Response Phone 7 Manifest Tracking Number WASTE MANIFEST J J K 5 Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) 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 11,Total 12.Unit HM and Packing Group(if any)) No. Type Quantity wt./VO. 13.Waste Codes 1. O a w z 2 w O 3 I 4, 14.Special Handling Instructions and Additional Information i 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 EPAAcknowledgment of Consent. I certify that the waste minimizatlon statement identified In 40 CFR 262.27(a)(ii I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generator's/Offerors Printed/Typed Name Signature Month Day Year –J 16.International Shipments Z1:1 Import to U.S. Export horn U.S. Port of entry/exit. Transporter signature(for exports only): Dale leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials � Transporter 1 PnntedJTyped Name Signature Month Day Year O a 4 Transporter 2 PrintedlTyped Name Signature Montt Day Year N 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue1 ❑Partial Rejection Fell Re ec6on Manifest Reference Number: F 18b.Alternate Facility(gr Generator) — U.S.EPA ID Number J � Facility's Phone: MAY 0 4 2016 W 18c.Signature of Alternate Facility(or Generator) Month Day Year i M vA�ll�_ i Z 19 Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 1. 2. 3. 4. 20.DesignatedFac lity Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 16a Pnnted[Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3.05) Previous editions are obsolete- TRANSPORTER'S COPY