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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 11.Generator IDNumber 2.Page I of 3.Emergency Response Phone 7g—Number WASTE MANIFEST I , , 3 J JJ 5.Generator's Name and Mailing Address Generator's Site K Address(if different than mailing address) Generators Phone: 6.Transporter I Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designaledfacility Name amO,ql!q Address,, L 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 HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes 0 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. Generators/Offeroes Printed/Typed Name Signature Month Day Year –J 16.International Shipments El import to U.S. ❑Export from U.S. Fort of entry/exit: Transporter signature(for exports only): Date leaving U.S.,* W17.Transporter Acknowledgment of Receipt of Materials Si Transpqrtqr,1jPrIntedtTyped Name, i 0 Signature Month Day Year IJ [Typed Name Signature Month Day Year Discrepancy 18a.Discrepancy Indication Space ❑ Quantity El Type FIResidue ❑Partial Rejection F]Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number U Uf Facility's Phone: uj 18c.Signature of Alternate Facility(or Generator) )ay Year !RMonth Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 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 Printedfryped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY