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Please print or type.(Farm designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1 1.Generator)D Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST ./ +` ' .=? 'tb ` J" $ z y f JJK- 5.Generator's Name and Mailing Address f Generator's Site Address(if different than mailing address) G Generators Phone: 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facilityi Naafe,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. 13.Waste Codes LU 3. 4. i I i 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 am a small quantity generator)is true. Generator's/Offeror'S Printed/Typed Name Signature Month Day Year ,r 16.International Shipments F— ❑Import to U.S. ❑Export from U.S. Port of entry/exit: R� f nature Transporter signature or exports only):P 9 ( p Y)' Date leaving U.S.: IX 17.Transporter Acknowledgment of Receipt of Materials E2 Transporter; Printed/Typed Name; Signature Year ® Month Day e r Transporter 2 Print � - / r ...� ed/Typed Name Signature Month Day Year F� 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type YP El Residue ❑Partial Rejection El Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number 0 L Facility's Phone: B18c.Signature of Alternate Facility(or Generator) Month Day Year 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) ® 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 t Printed/Typed Name Signature Month Day Year E I EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY I