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P.,lease print c'r 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 ResponsePhone.,a 4.Manifest Tracking Number (+ p WASTE MANIFEST G B 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 ! 8.Designated Facility Name and Site Address U.S.EPA ID Number Facility's Phone: ga. 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 P-101, 1 — � r . � LU Z 2. W 3. � fLL 14.Special Handling Instructions and Additional Information c 15. GEN ERATOR'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 and labeled/placarded,and are in all respects in proper condition for transport according to applicable intemational 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 EPAAcknowledgment 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. Generators/Offeror's PrintedfTypedName Signature Month Day Year . J 16.International Shipments T— ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Transporter signature(for exports only): i Date leaving U.S.: LO-' 17.Transporter Acknowledgment of Receipt of Materials r' Transporter 1 PrintedlTyped Name Signatur,''e Month Day Year °- ✓ Q Transporter 2 Printed/Typed Name Signature Month Day Year - of �— t— 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection r;. ' Manifest Reference Number: ti 181b.Alternate Facility(or Generator) U.S.EPA ID Number. J - - - U Facility's Phone: L01 18c.Signature of Alternate Facility(or Generator) Month Day Year a z - rq 19.Hazardous Waste Report Management Method Codes(Le.,codes for hazardous waste treatment,disposal,and recycling systems) o }. 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as need in Item 18a PrintedlTyped Name Signature Month Day Year EPA FOR 5700.22(Rev.3-05) Previous editions are obsolete.