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,.t - L ' JN f 1 M. `, z 4 Please print or type.,(Form designed for use on elite(12-pitch)typewnter:)y Form Approved.OMBNo.2050-0039 1 Generator ID Number 2.Page 1 of 3 Emergency Response Phone 4.Manifest Tracking Number UNIFORM HAZARDOUS ��„� �a 135 5� WASTE MANIFEST t` 5.Generator's Name and Mailing Address Generator'sSite Address(if different than mailing address) Generators Phone,,_-:, 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 c 'i,,aj .. Facility's Phone ga 9b.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. -h- 3.3. 3 .. -. .. 4. {{� 3 i j 14:Spedal Handling Instructions and Additional Information Oil- ` ,. , . . 15. GENERATOR SIOFFEROR-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 andlalieletl//piacarded,and"in a]respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary Exporter I cer6Jqnts 6(this consignment conform to the terms of the attached EPAAcknowiedgment 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. Generator s Pdntedlfypedplame Signature Month Day Year �. 16.International Shipments F ❑Import to U.S. ❑Export from U.S. Pod of entry/exit: Z- Transportersig nature(for exports only): Date leaving U.S.: W`17.TransporterAcknowledgment of Receipt of Materials ; Transporter I PrintedfrypedNameS(gnature Month Day Year r - Transporter 2 Pdntedrryped Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity, ❑ j ❑Full Rejection ❑Type ❑Residue Partial Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J_ V w Facility's Phone: qW 18c.Signature of Alternate Facility(or Generator) Month Day Year z 19.Hazardous Waste Report Management Method Codes(i.e„codes for hazardous waste treatment,disposal,and recycling systems) G L 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/fyped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05}Previous editions are obsolete. DESIGNATED FACILITY'S COPY