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�e print or type.(Form designed for use on elite(1'2-pitch)typewriter.) Form Approved.OMB No.2050-4039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST J J K 5.Generator's Name and Mailing Address Generator's Site Address(9 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 9b.U.S.DOT Description(indudirg Proper Ship Name,Hazard Class,l0 Number, 10.Containers 11.Total 12.Unit HM and Packing Group(d any)) No. Type Quantity tA4.itfot. 13.Waste Codes L t t r— B z 2. LU r 3. r I 4. I 14 Special Handling Instructions and Additional Intorrnati 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I he�eby declare that the contents of this consignment are fatly and accurately described above by the proper shipping name,and are classified,packaged, marked and labeled/placarded,and are in all respects n proper condition for transport according to applicable intemationat and national governmental regulations-If export shipment and I am the Primary Exporter,I certify that the contents of this consignmer"I conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 26227(a)(61 am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generator's/Offeroes PrintedlTyped Name Signature Month Day Year J 16.International Shipments J,` [_ ❑Import to U.S. ❑Export from U.S. Port of entry/exit .. Transporter signature(tor exports only): Date leaving U.S.: LM 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed(ryped Name Signature Month Day Year O 0. ti QTransporter 2 PrintedlTyped Name S gra are Month Day Year tY t- 18.Discrepancy 1 Ba.Discrepancy Indication Space El ouantRy, ❑Type Residue ❑Partial Rel"on ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U S.EPA ID Number J LL Faa7itys Phone: w 18c.Signature of Alternate Facility(or Generator) Monty Day Year Q Z U519.Hazardous Waste Report Management Method Codes(i. .,codes for hazardous waste treatment,disposal,and recycling systems) uJ c 1. 2. 3 4. 20.Designated Facility Owner or Operator:Certification of rec6pl of hazardous materials coven.d by the manifest except as noted in Item 1 a Pdnt lyped name Signature Momh Day Year EPA Form 8700.22(Rev.3-05) Previous editions are obsol te. 7srrro.(-�1!A T ED AC j'7 c';F4F9AT