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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 MANIFEST R 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) l.1 v I Generator's Phone: 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name US.EPA ID Number 8.Designated Facilily Name and Site Address U.S.EPA ID Number Facility's Phone:. 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) 13.Waste Codes No. Type Quantity WCNoI. 1. a O F W Z 2. L 3. 4. 14.Special Handling Instructions and Additional Informalion 15. GEN ERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,art are classified,packaged, marked and labeledlplacarded,and are in all respects in proper condition for transport according to appiicahle 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)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generator'sfOfferor's PrinledlTyped Name Signature Month Day Year 16.international Shipments F— ❑Import to U.S. ❑Export from U.S. Port of entrylexit: K Transporter signature(for exports only): Date leaving U.S.: iX LU 17.Transporter Acknowledgment of Receipt of Materials OTransporter 1 Printed/Typed Name Signature Month Day Year 4 Transporter 2 Printed/Typed Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue El Partial Rejection ❑Full Rejection Manifest Reference Number: H 1 Bb.Alternate Facility(or Generator) U-S.EPA ID Number J_ 0 LL Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Uay Year z 19,Hazardous Waste Report Management Method Codes(i.e_,codes for hazardous waste treatment,disposal,and recycling systems) LU ' 2. s. Notice: State of California requires generator to photocopy and mail to 20.Designated Facility Owner or Cl Certificalion of receipt of hazardous materials covered by the manifest except as noted in Item 18a QTSC with 30 days: Printed/Typed Name Signature P.0 Sox 400 EPA Form 8700-22(Rev,12-17) Frevious editions are obsolete. Sacramento, CA 95812-0400 GENERATOR'S INITIAL COPY