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Ple print se PPt Or type.(Form designed for use on elite(12-pitch)typewriter) Form Approved,OMB No,2050-00 UNIFORMHAZARDOUS -Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST G B F 5.Generalor's NameandMailing Address Generator's Site Address(if—different than maiJirg address) Generator's Phonei. 6.Transporter I Company U.S.EPA iLJ Number 2.Transporter 2 Company Name U.S.EPA ID Number S.Designated Facility Name and Site Address U.S.EPA ID Number I FaMi s Phone..?,.,-, "':A ga. 9b.U.S.DOT Oescription{including Proper Shipping Name,Hazard Class,ID Number, 1D.Containers HM and Packing Group Jif any)) 11.Total 12.Unit Na. Type Quantity ivol. 13.Waste Codes Wl LU 2. 3. 4, 14.Special Handling Instructions and Additional Information IA�a 15. GENERATO;Z'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 dassified,packaged, marked and labelediplaurded,and are in all respects in proper condition for transport according to applicable international and national governmental regulallons.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)(if I am a small quantity generator)is true. Generators/Offerers Printed(Typed Name Signature Month Day Year F�J 16.IntemaYonal hipmen�s E-71 EI Import to U.S. ❑Export from U.S. Port of entrylexil: 9 Transporter signature(for exports cNy): Date leaving U.S,: Lcl� 17.TransporterAcknoWedgmenT of Receipt of Materials LJ Transporter 1.P 606df.TyRed Name Signature Month Day Year CLe. mfr, Transporier z Printedfryped Name Signalure ka* Day Year,. 2Z 18.Discrepancy 18a.Discrepancy Indication Space Quantity ElType ❑Residue ❑Partial Rejection ❑Full Rejection it 18b.AlternateFacility(a,Generator) Manifest Reference Number. U.S,EPA ID Number (J Facility's Phone: LU 18c.Signature OrMlemale Facility(or Generator) I Month Day Year a Z I CD 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment disposal,and recycling systems) LU a -—1 2. 3. 4. 20.Designated Facility Owner or Operator.Certilicalion of receipt of hazardous Materials covered by the manifest except as nc(ed in Rem 18a Penledfryped Name Signature Month Day Year il!r I EPA Form 8700-22(Rev,3.05) Previous editions are obsolete.