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Please print or type. Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST L 1.-800-255 3924 i - ', 1-05161 G B F 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Generators Phone: 6.Transporter 1 Company Namer'C I U.S.EPA ID Number 7.Transporter 2 Company Name 3 U.S.EPA ID NumbEATUM177,69 8.Designated Facility Name and Site Address U.S.EPA ID Number Facility's Phone: .• PAM000516161 9a, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) 13.Waste Codes No. Type Quantity Wt./Vol. 1. O w z 2. L 3. 4. 14.Special 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,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. r7nera-tor's/Offeror's Printed/Typed Name Signature Month Day Year _j 1 16.International Shipments H ❑Import to U.S. ❑Export from U.S. Port of entry/exit: z Transporter signature(for exports only): Date leaving U.S.: CC w 17.Transporter Acknowledgment of Receipt of Materials 11- Transporter 1 Printedlryped Name Signature Month Day Year CL - r' QTransporter2 PrintedTyped Name Signature Month Day Ydar F 18.Discrepancy 18a.Discrepancy Indication Space ❑Full Rejection Quantity Ll Type ❑Residue ❑Partial Rejection' Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J V LL Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) C3 1 2. 3. 4. r!ed ated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Name Signature Month Day Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY