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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) -t y.a'.> 'd� Form Approved.OMB No.2050-0039 1 UNIFORM HAZARDOUS �Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4 Manifest Tracking Number WASTE MANIFEST ;'s �f( ( ��a�� JJK 5.Generator's Name and Mailing Addr"e. Generators Site Address(if different than mailing address) Generator's Phone; Ck ` 6.Transporter 1 Company Name U.S.EPA ID Number y 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number Facilitys Phone: ga. 9b.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 WtNol. O a 2. w 3. a 4. 14.Special Handling Instructions and Additional Pfonnation 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 dassified,packaged, marked'and labeled/placarded,and are in all respects in proper condition for transport according to applicable internationaland 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 EPAAcknowiedgment 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 smalrquantily generator)is true. Generator's/Offeror's Printed(Typed N�a�m'?ep Signature / Month D�Iay �Yeear E l: S" J 16.International Shipments F� i-- ❑Import to U.S. ❑Export from U.S. Port of entry/exit: ._..__ z Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials tE Transporter 1 Printed/Typed Name t Signature Month Day Year QTransporter 2 Printed/Typed Name Signature' Month Deq Year F 18.Discrepancy 18a.Discrepancy Indication Space ❑ quantity ❑Type ❑Full Re' ❑Residue Partial Rejection lection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number U ra Facility's Phone: w 18c.Signature of Altemate Facility(or Generator) Month Day Year a z 19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems) C 1. 2. 3. j ! � ') 4. 20.Designated Facility Owner or Operator;Certlficatien of receipt of hazardous materials covered by the manifest except,as noted in Item 18a Printed/Typed Name / Signature ,,, Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR