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Please print or type. Form Approved.OMB No.2050-0039 1 Generator ID Number 2.Page 1 of 3.Emergent Rersponse Phon 4 Manifest Tracking Number UNIFORM HAZARDOUS KS WASTE MANIFEST u 0,6 11 1 1 '0 19 S 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 6 8.Designated Facility Name and Site Address U.S.EPA ID Number w '14 Facility's Phone: 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,10 Number, 10.Containers 11 Total 12.Unit 13.Waste Codes HIM and Packing Group(if any)) No. Type Quantity wt.NOI. 0 Z 2. UJ 3. 4. 14.Special Handling Instructions and Additional Information r. i'l 0 VI "Ti"1 0, 4,) 1;n. 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 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. Generatoes/Offeror's Printed/Typed Name Signature Month Day Year _j 16.International Shipments F— 0 Import to U.S. El 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 LU I-- Transporter 1 Printed/Typed Name Signature Month Day Year Z Transporter 2 Pri ted/Typed Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space Quantity El Type ❑Residue ElPartial Rejection EIFUII Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number Facility's Phone: W18c.Signature of Alternate Facility(or Generator) Month Day Year Z CD 55 `19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) UJ 1 2. T. 4. C3 1 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.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY