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Please print or type. Form Approved.0i No,2050-0039 UNIFORM HAZARDOUS 1 1.Generator ID Number 2.Page 1 of 3.Emefgancy Response Phone 4.ManitestTracking Number WASTE MANIFEST �?p 5.Generalor's Name and Mailing Address Generators Site Address(if different than mailing address) A I� Generator's 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 Facility's Phone: 9a 9b.U.S DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 7.Total 12.Unit HM and Packing Group(if any)) No. Type Quantity1-T al 12.Unit 13.Waste Codes 1. O L LU Z 2. LU CD 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 Iaheledlplacarded,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 certily 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. Generator'sfOfferor's PrintedlTyped Name Signature Month Day Year 16.International Shipments ZLlImport 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 1 Printed/Typed Name Signature Month Day Year O a Z Transporter 2 PrintedfFyped Name Signature Month Day Year F-- 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection IZ 18h.Alternate Facility(or Generator) Manifest Reference Number: U.S.EPA ID Number J U LL Facility's Phone: W 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) 0 1. 2. 3 Notice:State of California requires generator to photocopy and mail to 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a DTSC with 30 dcl'y5: PrintedlTyped Name Signature P.0 Box 400 EPA Farm 8700-22(Rev.12-17) Previous editions are obsolete. Sacramento, CA 95$12.0400 GENERATOR'S INITIAL COPY