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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) 1.Generator ID Number Form Approved.OMB No.2050-0G39 UNIFORM HAZARDOUS 2.Page 1 of 4i Emergency Response Phone !I Manifest Tracking Number WASTE MANIFEST �� 5.Generators Name and Mailing Address Generato'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 8.Designated Facility Name and Site Address U.S.EPA ID Number Faclity's Phone: ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers HIM and Packing Group(if any)) 11.Total 12.Unit 13 Waste Codes No. Type Quantity Wt.Nol. L aO oC w z 2. LU C9 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)(it I am a large quantity generator)or(b)(f I am a small quantity generator)is true. Generators/Offeroes Printed/Typed Name Signature Month Day Year J 16.International Shipments Z 1:1Import to U.S. ❑Export from U.S. Port of entry/exit: ` Transporter signature(for exports only): Date leaving U.S.: w 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature 00. Month Day Year a Transporter 2 Pr nted/Typed Name Signature Month Day Year K H 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑ TYPe F-1 Residue ❑Partial Rejection ❑Full Rejection 18b.Alternate Facility Reference Number: lity(or Generator) U.S.EPA ID Number J U ra+ Facility's Phone: 18c.Signature of Alternate Facility(or Generator) Month Day Year a z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment.disposal,and recycling systems) Uj O 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 Prin M I yped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY