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Please print or type.(Form designed for use on elite(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 JJ K 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) T7;14i Generators Phoney: 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 and Packing Group if an Quantity wt./Vol. 13.Waste Codes HM 9 P( Y)) No. Type ty 1. O Z 2. W 3. 4. 14.Special Handling Instructions and Additional Information 15. GENERATOR'S/OFFEROR'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 certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment 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. re_nerator's/Offeror`I s Printed/Typed Name Signature Month Day Year -j 16.International Shipments H ❑Import to U.S. ❑Export from U.S. Port of entry/exit: z Transporter signature(for exports only): Date leaving U.S.: LM 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day Year O IL aTransporter 2 PrintedfTyped Name Signature Month Day Year I- 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Parfial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J V ram Facility's Phone: LU 18c.Signature ofAltemate Facility(or Generator) Month Day Year Q z w19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) C 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 18a Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY'S COPY