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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved,OMB No.2050-0035 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4 Manifest Tracking Number WASTE MANIFEST JJ 5.Generator's Name gnd 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,,Transpoder 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number Facllit es 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 WI.NOL 13.Waste Codes W 3. 4. 14.Special Handling Instructions and Additional information J- 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/ift. rded,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/Offeror's Printed/Typed Name Signature Month Day Year —+ 16,International Shipments I- ❑Import to U.S. ❑Export from U.S. Port of entry/exit z Transportersignature(for exports only): Date Igaving U.S.; W 17.TranspokerAcknowledgment of Receipt of Materials IE Transporter*Pdntedfryped�ame Signature C Month Day Year J Transporter 2 Pdntedfryped Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility,(or Generator) U.S.EPA ID Number J V LL Facility's Phone: 18c.Signature of Alternate Facility(or Generator) Month Day Year 19.Hazardous Waste Report Management Method Codes(Le.,codes for hazardous waste treatment,disposal,and recycling systems) p L 2. 3. 4. 20.Deslgnated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Pdnted/Typed Name Signature Month Day Year EPA Form 8700-22(Rev,3-05) Previous editions are obsolete. TRANSPOR7SR'S COPY