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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 Plpne 4.Manifest Tracking Number WASTE MANIFEST GB F 5.Generators Name and Mailing Address Generators Site Address(if different than mailing arida ss) 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,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. 2 2. I 3. � 4. I 14.Special Handling Instructions and Additional Information ' 15. GENERATOR'SIOFFEROR'S CERTIFICATION,: I hereby declare that the contents of this consignment are folly and accurately described above by the proper stopping 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 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)(if I am a small quantity generator)is true. Generators/Offerors PnntedRyped Name Signature Month Day Year 1I I&International Shipments F ❑Import to U.S. ❑Export from U.S. Pod of entrylexit: Transporter signature(for exports only): Date leaving U.S. w 17.TransporterAckmwletlgmenl of Receip of Materials OTransporter i Printed/7yped Name Signature Month Day Year CAP C Transporter 2 Printed/typed Name Signature Month Day Year K ♦ 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ElFullRejection Manifest Reference Number: 181b.Alternate Facility(or Generator) U.S.EPA ID Number J E5 sai Facility's Phone: w 18c.Signature of Alternate Facility lot Generates) Month Day Year Q 2 CP 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item taa Printedlryped Name Signature I Month Day Year i EPA Form 8700-22(Rev.3-05) Previous editions are obsolete,