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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 „( ;,. , r }... ¢ ): '/ r. t H' 1 t , ) �� 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) f Generat'A Phoned "' 4 �_:�'i j 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: 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)) No. Type Quantity Wt.Nol.LU 13.Waste Codes 2. W j 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 arp'a small quantity generator)is true. Genera tor's/Offeror's Pnnted/ryped Name Signature Month Day Year 16.International Shipments ` ❑Import to U.S. ❑Export from U.S,,, :' Port of entry/exit: ' Transporter signature(for exports only): Date leaving U.S.: W 17.TransporterAcknowiedgmenl of Receipt of Materials Transporter Pdnted/Typed Name Signature s Month Day Year r 8 QTransporter 2 PrInted/ryped Name t Signature a Month . Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity El Type El Residue El Partial Rejection El Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number V Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year B 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 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/ryped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. Gt-M,r-E��`F0n',c3 1M!`fyiAE, CV f