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.nrt�.�:✓ �` _• f��,�:a; s}<{j. �$GP.'3Ctl$iS't�f1r rt�r.��'�.�-�° Wr;i�',iiy�i��w w Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number Page: of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST ; - � •,.. K 5.Generators Name and Mailing Address JJ 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 Pacldng Group('d any)) 13.Waste Codes No. Type Quantity WtNol. Q w z 2. w O 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 EPAAcknowledgment 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)(91 am a small quantity generator)is true. Generator's/Offeror's Pdnted(Typed Name Signature - Month Day Year -.r 16.International Shipments i- ❑Import to U.S. ❑Export from U.S. Pod of entryl ? Transporter signature(for exports only): Date leaving U.S- LU17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed(Typed Name Signature Month Day Year O a rq Z Transporter 2 PrintediTyped Name Signature Month Day Year H 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity Type ❑ Rejection Partial Re'ectlon Ll FW Rejectiar Manifest Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U LL Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z r, 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 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 Printedfryped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY