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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050 0039 UPIffORM4 HAZARDOUS 1 Generator ID Number 2.Pae 1 of 3.Em en Re s 9 erg cy sponse Phone 4.Alan est Tracking Number WASTE MANIFEST a . 962 JJK 5 Generators Name and Mailing Address 'j( . Generators Site Address(if different than mailing address) IVO Gene rs Phone, , 6.Transporter 1 Company Name U.S EPA ID Number Transp iter 2 Company Name U.S.EPA ID Number r 8.Designated Faculty Name and Site Address U,6 EPA[D Number Faraliry's Phone: 9a. 9b U.S DOT Descnptron(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11 Total 12 Unit HM and Packing Group('d any)) No Typo 11 Total 12 Unit 13 waste Codes 1 OF ? _ 2 I c7 ' 3 4. I 14 Special Handling Instructions and Additional Information f 15 GENERATOR'SIOFFEROWS CERTIFICATION! I hereby declare chat 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 accDr&ng to applicable intemational and national governmental regulations If export shipment and i am the Primary Exporter,I car*that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I carti'fy 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/Offerors PrfnteolTypad Name Signature r Month Day Year J 16_International Shipments l' ` ❑Import to U S ❑Export from U.S Port of entrylexti Transporter signature(for exports only) Date leaving U.S. 17 T derAclmowledgmantof Receipt of Materials i Transpcltpr 1 P tedlTy Name Signew.• 1 Month DayYear Q T s a- nn_tdfTyped Name Signature Month Day Year A Jib" r, j n 18-Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Refection ❑Full Reject., Manifest Reference Number. 18b.Altemate Facility(or Generator) U.S EPA ID Number V ri Facilitys Phone W 16c Signature ofAltemate Facility(or Generator) Month De Year a z 19 Hazardous Waste Report Management Method Codes(i.e,codes for hazardous waste treatment,disposal,and recycling systems) Lu 1. 2. 3 4. e 20'Designated FacilAy Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrintedlTyped Name Sighature , Month D y Year z f7" , L2c r: iii mb {z i EPA Form 8700.22(Rev 3-05) Previous editions are obsolete.• DESIGNATED FACILITY TO GENERATOR