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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1 1,Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST - 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.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: 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group('tf any)) No. Type Quantity Wt.Nol. 13.Waste Codes 1. i O w z. z L :�;::,, .; +i, !:AS i-- AEROSOLS, ,=i_A1YI9 A1,;ts, 3. 4. Itri 14.Special Handling Instructions and Additional Information JV 4 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 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 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. Generator'slOfferor's Printed/Typed„Name Signature Month Day Year � 16.International Shipments F— El 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 Transporter 1 PdntedlTyped Name Signature 11 Month Day Year x . > O s N Q Transporter 2 Printed/Typed Name + Signature Month Day " Year t- 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number V Q LL Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrintedlTyped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. OE&GNAI ED FAC)LITY TO GENERATOR