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Please print or type.(Farm designed for use on elite(12-pitch)typewriter.) Form Approved OMB No.205HO39 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emargency Response Phone 4.Manifest Tracking Number WASTE MANIFEST SKS 5.Generator's Name and Making Address Gen mnoys Site Address(If different than mailing address) Goneratofs Phone: S.Transposer 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPAID Number B.Designated Facility Name and Site Address U.S.EPA ID Number Fadlitys Phone: 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Gass,ID Number, 10.ConleNem 11,Total 12.Unit HM and Packing Group(if any)) No. Type Daintily, wM. 13.Waste Codes 1. C QO z Z. w t, 3. 4. 14.Special Handling lnstiuclonsandAdditimal lnfomnation 15. GENERATOR'SIOFFEROR'SCERTIFlCATION:I herebydeclere that the contents ofthis consignment are fully and accurately desuihed above by the proper shipping name,and are detested,packaged, marked and labeled/placarded.and are in all respects in proper condition for transport according to applicable Ntemationalend national governmental regulations.If exportshipmentand I am the Primary Exporter,I certify that the contents of the consignment conform to Oce terms of the adaGletl EFAAcknuwledgment of Consent. I cemly that the waste minimizabon statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)a(b)(If I are a sinal quantity generator)is he. GenaratofsrOgemrs Printed7fyped Name Signature Month Day Year _r 16.International Shipments H 11 Import to U.S. ❑Export from U.S. Port of entrylexh: z Transporter signature(for exports only): Date leaving U.S.: w 17.TransporlerAcknovAedgment of Receipt of Materials „~. Transporter 1 Pn t dlfyped Name Signature Month Day Year a n G Transporter Printedirlyped Name Signature Monty Day Vear ce j18.Discrepancy 11i Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Road. ❑Futl Rejedon Manifest Reference Number. 16b.Alternate Facility(of Generator). U.S.EPA ID Number J 4.y LL Faciliys Phare: 16c.Signature ofAOemate Facility(or Generator) Munih Day Year Q z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste ueatmen4 disposal,and recycling systems) 1. 2. 3. 4. 20.Designated Facility Owner a Operator.Certification of receipt of hazardous materials covered by the mere feslexcept as noted in Item 18a Print vped Name Signature Monty Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR