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Please print or type. Form designed for use on elite(12-pitch)typewriter) Form Approved.OMB No.2050.0039 UNIFORM HAZARDOUS 1.generator ID Number 2.Page 1 of 3.EmeTgencay Response Phone 4.Manifest Track�iing Number g /�l�' WASTE MANIFEST Q o r F IYF Y Y 5.Generator's Name and Mailing Address Garerator's Site Address(if different than mailing gess) Generator's Phone: 6.Transporter I Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number B.Designated Facility Name and Site Address U.S.EPA ID Number Facill es Phone: 9a. 9b.U.S.DOT Description(including Proper Shippirg Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nd. 1. ! q� Z 2. uj 3. 4. 14.Special Handling Instructions and Additional Information 15. GENERATOR'SNOFFEROR'S CERTIFICATION: I hereby declare that the amts 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 international and natal govemmentai regulates.ff export shipment and I am the Primary Exporter,I certify Brat the contents of this consignment corrfomn to the terms of the attached EPAAcknawledgment of Consent I certify that the waste minimization statement identfied in 40 CFR 262.27(a)(if I am a large gcentity generator)or(b)(if I am a small quantity generator)is true. Generator's/offerors Printeigyped Name Signature Kit Day Year Ai -j 16.International Shits ❑Import to U.S. ❑Export from U.S. Port of enlrylexit: Transporter signature(for exports only): Date leaving U.S.: d' 17.TransporterAcknowledgment of Receipt of Materials Transporter 1 Printed Typed Name Signature Month By year 11 ! ! to C Transporter 2Prnted7ypedName Signature Month Day Year fr 18.Discrepancy tea.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Pard Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Gerrerator) U.S.EPA ID Number J_ V Facility's Phone: W 18c.Signature of ABernate Facility(or Generator) Month Day Year iQ 2 US19.Hazardous Waste Report Management Method Codes(.e.,codes for hazardous waste treatment,dial,and recycling systems) Uj 1. 2. 3. 4. 20.Designated Facility Owner or Operator:Certificates of receipt of hazardous materials covered by the manifest except as noted m Item lea PrintedlTyped Nerce Signature Month Day Year EPA Form 8700.22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY