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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 Phone 4.Manifest Tracking Number WASTE MANIFEST 8 G B F I ' S.Generators Name and Mailing Address Generator's Site Address(H different than mailing address) J% Generators Phone: 6.Transporter l Company Name .) U.S.EPA ID Number 7 Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number =aclhh's Phone: ge, 9b.U.S.DOT Desorption(including Proper Shipping Name,Hazard Class,ID Number, 10.Cori m1 it.TOUI 12.Unit HM and Packing Group(if any)) / No. Type Quantity W1.Nol. 13.Waste Codes Ix q _) 5 w 3. 4 14.Special Handling Instructions and Additional Information 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby dedare that the contents of this consignment are fully and accurately described above by de proper shipping name,and are classified,packaged, marked and latheladlplararded,and are in all respects In proper condition for transport according to applicable intematbnatand national governmental regulations.If export shipment and I am the Primary Exporter,I cedly that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. 1 I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(itI am a small quantity generator)is true. G__en//eratorslOffemrs Printecirryped Name - l Signature Month Day Year —11 ,nlernahonal Shipments F ❑Import to U.S. ❑Export from U.S. Part of entry/exit: = Transporter signature(for exports only): Date leaving U.S: W 17.T2nspolerAcknovdedgment of Receipl of Materials ~y. Transporter l Prnted9'yped Name Signa Nre Month Day Year l y Maxx u i /A/ ( r Q Transporter 2 Printecirlyped Name Signature Month Day Year I 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quart ❑T ❑Residue My Type Patel Reledion Ful Rejection Manifest Reference Number. 181b.Alternate Facility(or Generator) U.S.EPA ID Number J 0 LL Facilitys Phone: W 18c.Sgnefure of Alternate Facility(a Generator) Month Day Year Q Z 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.CeNficatbn of receipt of hazardous materials covered by the manifest except as noted in Item 18a 11 Printedrryped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOWS RMIIAL COPY