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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 "+ �� 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) Generator's Phone: 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 Unit HM and Packing Group(if any)) No. Type Quantal 12 12..Unit 13.Waste Codes Z 2 W t7 3. 4. 14.Special Handling Instructions and Additional Information p . . rq VI 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, Generator's/Offeror'sPrinted/Typed Name Signature Month Day Year -.r16.Intemational Shipments F ❑Import to U.S. ❑Export from U,S. Port of entry/exit: Z Transporter signature(for exports only): Date leaving U,S.: I 17.Transporter Acknowledgment of Receipt of Materials WW X Transporter 1 Pdnted/lyped Name C o Signature Month Day Year N . � Transporter 2 PdntedlTyped Name o Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space E] Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection 18b.Alternate Facility(or Generator) Manifest Reference Number: U.S.EPA ID Number _J 0 I Facility's Phone: W 18c.Signature ofAltemate Facility(or Generator) Month Day Year a Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LU 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 Printedrryped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. � � Et$sr � S ' - ITIAL, COPY