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Please pant oitype. (Form designed for use on elite (12-pitch) typewriter.) Form Approved. OMB No. 2050-0039 UNIFORM HAZARDOUS 1 . Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number C WASTE MANIFEST _ - FLE 5. 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. EPAID Number 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address U.S. EPA ID Number Aw Facility's Phone - Da. 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)) No Type Quantity wt./Vol. 13. Waste Codes 1. K 0 w z 2. Ulu C7 I 4. 14 Special Handling Instructions and Additional Informal 1'ol ECf NUr lbVC 16427;l 15. GENERATOR'SIOFFEROR'S CERTIFICATION: Ihereby 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 car ily 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 Printed/Typed Name bignalure Month Uay year 16. International Shipments IF— ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit z Transporter signature for exports only): Date leaving U.S.: Cle 17. Transporter Acknowledgment of Receipt of Materials KTransporter i Printed/Typed Name Signature _ Month Day Year a I - v..,..._...._i 3 Transporter 2 PrintedlTyped Name Signature Month Day Year F 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantl [I ❑ j El Full Rejection ty El Residue Partial Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number U a LL Faciloys Phone: w 18c. Signature of Alternate Facility (or Generator) Month Day Year Q z 55 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 0 1 . 2. 3. 4. 20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted Im Item 18a ProadRyped Name Signature Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. - GENERATOR'S INITIAL COPY