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Please print or type.(Form designed for use on elite(12-pitch)typewriter) Form Approved.OMB No.2050-0939 1.Generator ID Number 2,Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number �•., UNIFORM HAZARDOUSt Y ,p s u @� WASTE MANIFEST J J K 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 7.Transporter 2 Company Name `% U,S,EPA ID Number B.Designated Facility Name and.Site Address "' U,S.EPA ID Number Facility's Phone; ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazartl Class,ID Number;' 10.Containers 11.Total 12.Unit 9 Group and Packin if an ! HM P( Y)) •No. Type Quantity. Wt.Nol. 13.Waste Codes 0 2. 3, 4. 14.Special Handling Instructions and Additional information 15. GENERATOR'S/OFFEROWS 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 attached EPAAcknowiedgment of Consent.. . I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantitygenerator)or,(b)(if[am a small quantity generator)is,true. Generatorsl0+f�e4ofdnted/Typed NaeY Signature ,�" f f j T f Mogth Day Year' 4,x' 1 tz.:.,}vJ 1 d.....l ,r! { -J 116.International Shipments 1- ❑Import to U.S. ❑Export from U.S, Port of entry/exit: Z Transporter signature(for exports only): Date leaving U.S.: 04 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed Efpe Name ( Signature f 'it r Month Day Year G7 Q Transporter 2 Printedffyped Name Signature Month y Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ quantity ❑Type ❑Residue ❑Partial Rejection El Full Rejection Manifest Reference Number: 18b,Altemate Factlity(or Generator) U,S:EPA ID Number J V ►ai- Facilitys Phone: LOU 18c.Signature of Alternate Facility(or Generator) Month Day Year Z - 1Q 1 y19.Hazardous Waste Report Management Method Codes(Le.,codes for hazardous waste treatment,disposal,and recycling systems) Uj 1. ! 2. 3. 4. 20,Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except-as nctediri Ttem 18a Pdnted/fyped Name i jSignature rt a ( Month Day Year EPA Form 8700-22(Rev.3.05) Previous editions are obsolete, TRANSPORTER'S COPY