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* I -rE=- MO sol Please print or type.(Form designed forAw nn alito(12-pitch)typewriter.) 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 G B F 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) 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: 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(if any)) No Type Quantity WI NoL 1. O W Z 2. W RE EIV D 3. jUl. 17 2 18 4. ENVIRONMENTAL HEALTH DEFARTNIE T 14.Special Handling Instructions and Additional Information 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 labeled;placarded,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 certihy that the contents of this consignment confoirn to Ine terms of the attached EPA AckpOedgment 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, Generators'Offerors PrirdedfTyped Name Signature Month Day Year —J 16.International Shipments I 7 Zimport to U.S. ❑Export from U.S. Port of entry/exit Transporter signature(for exports only). Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials i2 Transporter 1, ntedITyped Name = Signature Month Day Year a x Z Transporter 2 Print&/Tped Name Signature Month Day Year Q� a F 18.Discrepancy 18a Discrepancy Indication Space r Quantity Type Residue Partial Rejection Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J_ V 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) o 1 Z 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrinI 'Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. TRANSPORTER'S COPY