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Please print or type.(Form designed for use on elite(12 pitch)typewriter.) Farm Approved.OMB No.2050 0p3g UN{FORM'HAZARDOUS 1 0enetorl4Jlumber ,, i„ 2.Page 1 of 3 Emergency Response Phone 4.Manifest Track(ng Numbed WASTE MANIFEST A 4 37g 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) Generator's Phone W:- 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 '_ Facilitys Phone. - ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.ContainersI 11.Total 12:Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. W 3. _ 4. t N.Spetl Handling instructions and Additional Information 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,aril are classified,packaged, marked and labeted/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,l ceitifythafthe contents of this consignment conform to the terms of the attached EPAAcknowiedgmentof Consent. i cerpfy 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. Generator`s17erors PdntedfTy*Name Signature Month Day Year -J 16.Intemationai S menu } NP - „ ❑Import to U.S, El Export from U,$,,, Port of entry/exit: Z Transporter signature(for exports only): Date leaving U,S: tau 17 TransporterAcknowledgment of Receipt of Materials r, TranspOer1 Printed/LypedVame Sghature t Mppnnth Day Year14 ,, Z Transporter 2 Pnnted/Typed Name "Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space 0 Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA ID Number U L Facllitys Phone: LU 18c.Signature ofMtemate Facility(or Generator) Month Day Year a z N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 1. 2. 3. 4. t 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a _."_... Month Day Year Printed(fyped Name Signature .�� ,....�---°�""' � EPA Form 8700-22(RevJ3-05) Previous editions are obsolete. DESIGNATED FACILITY'S COPY