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Please print or type. Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1 Generator ID Number 2,Page 1 of 3,Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFE I ;,`t - G B F S.Generator's Name and Mailing Address Generator's Site Address(if different than mailing ad ress 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 US-FPA 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 Quantity WYVol, 1, Q Q Z 2. LU LD 3, 4. 14.Special Handling Instructions and Additional Information 15, GENERATOR'S10FFEROR'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 labeledlplacarded,and are in all respects in proper condition for transport according to applicable intemational 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 26227(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is two, GeneratorslOfferors PrintedlTyped Name Signature Month Day Year 16.International Shipments ❑Import to U.S. ❑Export from U.S Port of entrylexit: ? Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Transporter t PrintedlTyped Name Signature ,ter Month Day Year a Z Transporter2 Printe &Typed Name Signature ,, flonth Day Year H 18,Discrepancy 181,Discrepancy Indication Space ❑ quantity ❑Type ❑Full Re El ❑Partial Rejection Roil Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J_ U LL Facility's Phone. LL, 18c.Signature of Alternate Facility(or Generator) Month Day Year a 1 1 Z y19.Hazardous Waste Report Management Method Codes(i,e.,codes for hazardous waste treatment,disposal,and recycling systems) Notice: State of California requires 1' 2- 3. generator to photocopy and mail to 20.Designated Facility Owner or Operator.Certfication of receipt of hazardous matenais covered by the manifest except as noted in Item 181 TSC with 30 days: PhritedlTyped Name Signature P.0 Box 400 Sacramento, CA 95812-0400 EPA Form 8700-22(Rev,12.17) Previous editions are obsolete. GENERATOR'S INITIAL COPY