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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Farm Approved,OMB No.2050-0035 UNIFORM HAZARDOUS 1 Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST G B F- 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 1D 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 Cuaritity Wt.NoL 1. rY O Q W Z 2. LU c� 3. 4. 14,Special Handling Instructions and Additional Information 15- GENERATOR'SfOFFEROR'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 iabeledlplacarded,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 EPAAcknow€edgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262-271(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generator'sfOfferor's PrintedlTyped Name Signature Month Day Year 16-Intemational'Shipments i= ❑Import to U.S. ❑Export from U-S. Pont of entryiexit: z Transporter signature(for exports only): Date leaving U.S.: w 17,TransporterAcknowledgment of Receipt of Materials ce Transporter 1 Pdntedlfyped Name Signature Month Day Year O a Z Transporter 2 PrintedlTyped Name Signature Month Day Year r 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity DType E Residue Ll partial Rejection Ll Full he}ection Manifest Reference Number 1 Sb.Alternate Facility(or Generator) U-S.EPA ID Number U U- Facility's Phone' LOU 18c.Signature of Alternate Facility(or Generator) Month Day Year a --- — ----- _ -- I I w19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems l Notice: State of California requires gernerator to photocopy and mail to 20L Dirrignated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in iter DISC with 30 Bays: PrintedlTyped Name Signature p•0 Box 400 ear Sarramantra rn QR3217-il EPA Form 8700-22(1 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY