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Please print or type.(Form designed for use on elite(12-pitch)typeuvritec) Form Approved,OMB No,2050-0039 UNIFORM HAZARDOUS 1.Genemlor ID Number 2.Page 1 cf 3.Emergency Response Phone 4.Manifest ng Number WASTE MANIFEST ° 000197620 M W 5.Generator's Nara and Mailing Address Genwatoes Site Address(ddifferent than mailing address) Generator's Phone: B.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Faility Name and Site Address U.S.EPA 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(d any)) No. Type Quantity WLfvol. U' 2. 5 3. 4, 14,Special Handling InsInuctions and Additional Information 15. GENERATOWSIOFFEROR'S CERTIFICATION: I hereby tare that the contents of this consignment are fully and accurately descry above by the proms shipping name,and are classified,packaged, marked and labeled/placarded,and are in afi respects in proper cordtion for transport according to applicable international and national governmental regulons.[(export shipment and I am the Primary Exporter,I certify that Its contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identifled in 40 CFR 262.27(a)(if I am a targe quantity generator)or(b)(II am a small quantity generator)is true_ Gererator'"emes Printedfryped Name Signature Month Day Year 71 16.International Shipments ti ❑Import to U.S. Export frau U.S. Port of entrylexit: Transporter signature(for exports only): Dad leaving U.S.: 17.TmnsporlwAckn owl dgrrartt of ReoNpt of Materials cc Tie ame naporoer 1 PdnwVryped NaSignature Month Day Year <K Transporter 2 Printedrryped Name Signature - Month Day Year 16.Disaepency 18a.Discrepancy Irdrcatfan Space ❑ quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Reject on Manifest Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA ID Number J Facility's Phone: 18c.Signature of Alternate Facility(or Genera) Month Dal' Year 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) ® 1. 2. 3. 4. 20.Denigrated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the mardfest except as noted in Item 18a Pdntu3dlfyped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY