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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved,OMB No.2050-0039 1.Generator ID Number Manifest Tracking Number JJK UNIFORM HAZARDOUS WASTE MANIFEST 5,Generators Name an Mailing Address Generator's Site Address(if different than mailing address) J Generator's Phone: U.S.EPAIDNumber 6.Transporter 1 Company Name T "P" U.S.EPA ID Number 7.Transporter 2 Company Name 8.DesignilU.S.EPA ID Number e F cifty Nam?"a,pol S e Address it Facility's Phone:' Ing Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes 9a, 9b.U.S.DOT Description(including Proper Shipp Type Quantity Wt,N0I. HM and Packing Group(if any)) 0 LLJ 2E 2. LU 3. 4. ......... ..... .......... IC Special a311ig i i01S and 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 certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment 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. Generator's/Offeror's Printed/Typed Name Signature Month Day Year El Export from U.S. .7 16.International Shipments Fort of entry/exit: F— El imp-rt to U.S. Date leaving U.S.: M Transporter signature(for exports only): fk' 17.Transporter Acknowledgment of Receipt of Materials Month Day Year UJ Transportered Name Signature 0 Ck- Transporter 2 ntedfTyped Name Month Day Year W Signature 18.Discrepancy 18a,Discrepancy Indication Space El Quantity El Type El Residue ❑Partial Rejection ElFull Rejection Manifest Reference Number: U.S.EPA ID Number 18b.Alternate Facility(or Generator) -I Facility's Phone: Month Day Year 18c,Signature of Alternate Facility(or Generator) UJ 0 19.Hazardous Waste Report Management Method Codes(i.e,,codes for hazardous waste treatment,disposal,and recycling systems) LLJ 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 Signature Month Day Year Printed/Typed Name GENERATOR'S INITIAL COPY EPA Form 8700-22(Rev.3-05) Previous editions are obsolete.