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Please print or type.(Forrr':designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0038 UNIFORM HAZARDOUS 1,Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST SKS 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) Generators Phone: 6.Transporter 1 Company Name U.S.EPA ID Number 7,Transporter 2 Company Mama U.S.EPA JD Number 8.Designated Facility Name and Site Address U.S.EPA ID Number Facility's Phone: - - ga 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 1. I Z 2 LE.I C7 3, 4. 14.Special Handling Instructions and Additional Information 15, GENERATOR'SIOFFEROR'S CERTIFICAT)ON: 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 labeledlplacarded,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 EPAAcknowledgment 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)(Ill am a small quantity generator)is true, Generator'siOfferors PdntedTryped Name Signature Month Day Year J 16.International Shipments i— intini U.S. ❑Exportfrom U.S. Pori of entrylexif. Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials 4' Transporter I PrintedlTyped Name Signature - Month Day Year O rn ac Transporter 2 Printed/Typed Name Signature Y, Month Day Year rX F 18.Discrepancy 18a,Discrepancy Indication Space 1:1 Quantity L1 Type ❑Residue ❑Pallial Rejection ❑Full Rejection Manifest Reference Number; 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U Facility's Phone: Lu 18c.Signature of Alternate Facility(or Generator) Month Day Year Zz F) 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 PrintedlTyped Name Signature Month Day Year EPA Form 8700-22(Rev.3.05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR