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Please print or type. (corm oeslgnea Tor use on elite ( iz-pitcn) typewriter.) I UIIII mplilumu. VIVID INu. &v -- UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number p WASTE MANIFEST JJ 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: got 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes No. Type HM and Packing Group if an 9 P ( Y)) Quantity ty Wt.Nol. O Z Z w 0 3. _ 4. 14. Special Handling Instructions and Additional Information <,'.E. T i,I.0 sa�{1NC, 15. GENERATOR'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. rratoft/Offeror's Printed/Typed Name Signature Month Day Year J F-- 16. International Shipments ❑ Import to U.S. El Export from U.S. Port of entry/exit: = Transporter signature (for exports only): Date leaving U.S.: LW 17. Transporter Acknowledgment of Receipt of Materials �2 Transporter 1 Printed/Typed Name Signature Month Day Year 0 M co Name Signature Month Day Year [77��ed/-Fyped 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑Residue El Partial RejectionRejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number C> L Facility's Phone: l® 18c. Signature of Alternate Facility (or Generator) Month Day Year a Z CD 19. Hazardous Waste Report Management'Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) I 1. 2. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Ll20. PrintedlTyped Name Signature Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete.