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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 MANIFEST7 �� uae ;t 5.Generator s 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 x i l r„uj i; slit 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designgte(1 Fagi i Name aPd Site.Address, U.S.EPA ID Number [ .;� r .r! it P .r r.,.. i�l�'.. 1 r f s l f f ' 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 WtNol. 2. W I 0 I 3. i i I i 4. s I 14.Special Handling Instructions and Additional Information i PLw i 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 internationail(rd national govern6tai 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 40PCFR 262.27(a)(if i am a large quantity generator)or(b)(If I amk small quantity gnerator)is true. Generatgrs/Offerors Printed/Typed Name Signatu e• " M nth Day Year r 16.International Shipments ¢ ❑Import to U.S. ❑Export from U.S. ; P(o of entry/exit. t o ® 'transporter signature(for exports only): is leaving U.S.: 17.Transporter Acknowledgment of Receipt ofMaterials Transporter 1 Printed/Typed Name / Signature Month Day Year CL ZTransporter 2 Printed/Typed 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 t� 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) ® `1 T 3. 4. ..................... 7 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printedffyped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERA'TOR'S INITIAL COPY