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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 14.Manifest Tracking Number WASTE MANIFESTJJ K 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Generators Phone: 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility N@me Epgd Site Address U.S.EPA ID Number Facility's Phone: 9a. 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)) 13.Waste Codes No. Type Quantity Wt.Nol. ) 2. LU f s 3. 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 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. Generators/Offerors Printed/Typed Name I t Signature f r v Month Day Year ri16.International Shipments ° t-- ❑import to U.S. ❑Export from UlS. Port of entrylexit: Transporter signature(for exports only): , Date leaving U.S.: 17.Transporter Acknowledgment of Receipt of Materials LLI s Transporter 1 Printdffypd Name Signature Month Day Year Transporter 2 Printed/Typed Name Signature Month Day Year n 18.Discrepancy 18a.Discrepancy Indication Space quantity ElT e yp ElResidue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number U Facility's Phone: UJ 18c.Signature of Alternate Facility(or Generator) Month Day Year 2E rn19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) Q 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. GENERATOR'S INITIAL COPY