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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.ONIB No.2050-0039 1.Generator ID Number 72Page of3.Emergency o_s....__=R,.___UNIFORM HAZARDOUS �; '��„��,�� _....__..._ ...._. _. __. WASTE MANIFEST JJK 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: - 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 Wt.Nol. p - w Z 2. LU s 3. i J a3I; ,pG jj 14.Special Handling Instructions and Additional Information 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 classed,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. -- --_ Generatoes/Offeroes Printed/Typed Name Signature Month Day Year 16.International Shipments F- ❑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 Printed/Typed Name Signature Month Day Year ZTransporter 2 PrintedlTyped Name Signature Month Day *Year �G ks s- 18.Discrepancy Quantity 18a.Discrepancy Indication Space ❑ quantity ❑Type Ll Residue ❑ ❑Full Rejection Rejection a Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J_ V LL Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year a Z N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LAJ1. 2. 3. 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 Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESi ' NAT E0 1=ACUL177 70 ,ZM BATOR