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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.Pape 1 of 3•Emergency Response Phone 4 Manifest Tracking Number WASTE MANIFESTJJK ` � � - 5.Generator's Name snd Mailing Address "Generator's Site Address(if different than mailing address) Generator's Phone: 1. ' Ot- 6.Transporter.1 Corrpahy Name U S EPA ID Number 7 Tran9porter•2 Company Name ; U S EPA ID Number 8:Designated,Facllity Neme:and.SiteAddress U•S.EPA ID Number Facifi s Phone. ; ga 9b•.U.S,DOT Description(Including Proper Shipping Name,Hazard.Class,ID Number, 10.Containers 11.Total 12,Unit 13.Waste Codes HM and Packing Group(If any)) No. Type Quantity Wt.Nol. Z 2. 3. 4. . 14.Special Handling Instructions and Additional Information 15. GEN.3RATORWOFFERPR'S CERTIFIC�IT11 ION: 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/piaoarded,and are in all respedstn 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 wnsignment conform to the terms of the attached EPAAcknowledgment of Consent. I certify that ifie waste mihimizatlon statement Identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantitygenerator)is true, Generator,s/Offerors Printed/Typed Name Sigr)ature Mont Day Year .�j 16,International Shipments F- Import to U.S. ❑Export from U.S. Port of entry/exit: Z Transporter,signature(for exports only): Date Igaving U.S.: 19.Transpoiierklinowledgment of Receipt of MaterialsjE tr f w r Transporter'41.RriHled/.Eyped�Name 4 9 Signature Month Day Year� 6 C � f I ,i ..,� r Month ' Day Year Trlin§porter2PrintdfypedName g 18.Discrepancy 18a,Discrepancylndication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number v Ll. FacllltysPhone: .. W 18c,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) G 1. 2, 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a P me yped erne Signature Month Day Year EPA Form 8700-2.2(Rev.3-05) Previous editions are obsolete. TRANSPORTER'S COPY