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Please print or type.(Farm designedforuse on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1 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) Generators Phone'. B.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name US.EPA ID Number B.Designated Facility Name and Site Address U.S.EPA 0 Number Facility's Phone: 9e 96.U.S.DOT Description(Including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12,Unit HM and Packing Group(If any)) No. Type Quantity Wt.Ml. 13Waste Codes . 1. O K w z w f7 _ 3. 4. F 14.Special Handling Instructions and Additional Information y.: l n 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, madded and labeledleaarded,and are in all respects in proper condition for transport according to applicable international and national govemmental regulations,If export shlpment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimizadon statement Identified to 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(If I am a small quantity,generator)Is tree, Generators/Offarar's Parboi yped Name Signature - Month Day Year 16.International Shipments f— Ll Import to U.S. ❑Expert from U,S. Port of entry/exit Transporter signature(for exports only): Date leaving U.S.: W 17,Transporter Acknowledgment of Receipt of Materials W Transporter 1 PrintedlTyped Name Signature Month Day Year O a N QTransporter Printed/Typed Name Signature Month Day Year K r 18.Discrepancy 1 Be.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection Full Rejection Manifest Reference Number. 18b.Abernate Facility(or Generator) - U.S.EPA ID Number J U .LL Facillty's Phone'. pj 1Be.Signature ofAlmmate Facility(or Generator) Month Day Year Q Z 1B.Hazardous Waste Report Management.Method Codes(i.e.,codes for hasardous waste treatment,disposal,and recycling systems) G 1. 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted In Item 16a Ily Printeirryped Name Signature Month Day Vear EPA Form 6700-22(Rev.3-05) Previous editions are obsolete. TRANSPORTER'S COPY