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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050.0039 UNIFORWf DOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest ��Tracking Number �� WASTE MANIFEST �J P M V Y 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) Gererator'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 � r Facility's Phone: 9a 9b U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers it Total 12.Unit 13.Waste Codes HM and Parking Group(if any)) No. Type Quantity Wt.Nol, O Z2. 3. 4 14.Special Handling Instructions and Additional Information '3` f'.f9 t;•' 1`T�'f T'9 15. GENERATOR'SIOFFEROR'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 international and national governmental regulations.It export shipment and I am the Primary Exporter,I cerbly that the contents of this consignment conform to the terms of the attached EPAAckwMedgment of Consent. I certify that the waste minimization statement identified In 40 CFR 262 27(a)(H I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generator's/Offeroes Prinledlfyped Name Signature Month Day Year J 16,International ShipmentsJr Import to U.S. ❑Export from U.S. Port of enhylexit Fl Transporter signature(for exports only): Date leaving U S.: W 17.Transporter Acknow edgment of Receipt of Materials a Transporter 1 PnntedlT"Name Signature Moplh Day Year Z Transporter 2 Prints V Name Signature Month Day Year Q 18.Discrepancy -.. ' 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number _J V tai Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year a Z N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) G 1. 2, T - 20. Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 14 Pnnted(Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR