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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050.0039 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number. UNIFORM HAZARDOUS WASTE MANIFESTS a JJ K 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) Generator's Phoney 6.Transporter 1 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 t 1 B �Q4Uf H F.lvff a I l iiE-'jT.-.14C iw;,1Ef•t"f Facility's Phone: 9a 91b.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. O Z 2. w c� 3. 4. 14.Special Handling Instructions and Additional Information 23'si)p''rf.:ttil, a+i'r 70 BE! 1F. B,Z9) `t..i ;' t= '.f''1'!'sr.. _.i.a }f,1"!'F' 15. GENERATOR'S/OFFEROR'S 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 the attached EPA Acknowledgment of Consent. I certifythat 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/Offeror's Printed/Typed Name Signature - Month Day Year 16,International Shipments H ❑Import to U.S. ❑Export from U.S. Port of entry/exit: z Transporter signature(for exports only): Date leaving U.S.: w 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 PrintedlTyped Name Signature „ Month Day Year a. Z Transporter 2 Printed/Typed Name Signature Month Day Year rr 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantityyp ❑T e ❑Residue El Partial Rejection El Full Rejection' Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J v rat Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year a z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LLI G 1 �, t � 2. 3. 4. i 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESMI AL ED FACILp ITV'S COP'S