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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 JJK 5.Generator's Name and Mailing Address Generators 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 US.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number 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 WtNol. Ix D W I � W 2 1 I i 3. f 4. } f 14 Special Handling Instructions and Addibonat lAformation 15. GENERATOR'S/OFFEROR'S CERTIFICATION:1 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 shipmentand I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAckrwwledgment of Consent. 1 cerfify 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/Ofteroes Printedfryped Name Signature Month Day Year —r 16.International Shipments Z ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Transporter signature(for exports only): Date leaving U.S.: W 17.TransporterAcknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month, Day Year: O rs ; Qz Transporter 2 Printed/Typed Name Signature Month Day Year t- 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type El Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number v u4 Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z 55 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) G 1. 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 Printedlryped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY'S COPY