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Pease'Print or±ype.(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 MANIFEJ l '✓ 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.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 Faiility's Phone: 9a, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 712itHM and Packing Group(if any)) 13.Waste Codes No. Type Quantity 1. O - t Z 2. 1 � f f 3. " = t 4. 14.Special Handling Instructions and Additional Information y. 15. GENERATOR'S/OFFEROR'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. enerator's/Offeror's PrintecItTyped Name signature Month ga—y -7e—a—r J 16.International Shipments - z ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Transporter signature for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed NameSignature Month Day Year O I I I I a QTransporter 2 Printed/Typed Name Signature Month Day Year t- 18.Discrepancy 18a.Discrepancy Indication Space I Full Rejection Quantity ElType ❑Residue ❑Partial Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J_ V ' Q LL Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Cay Year Q Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) UJI a 1 2. T 4. 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name SignatureMonth Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY M GENERATOR