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7) 9 ease print or type.(Form designed for use on elite 12-pitchf typevvdter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Genitor ID Number 2.Page 1 of 3.Emergency Response Phone +4.M613425516 !fest Tracking Number WASTE MANIFEST i._ ��,, j.--�. ;s;�t-f • `��y { I ,� 613 4 2 5 516 JJ K 5.Geen.erator's Name and Mailing Address Generator's Site Address(if different than mailing address) .J Generator's Phone: 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 6.Designated Facility Name and Site Address U.S.EPA ID Number Facility's Phone: ga. 9b.U.S.DOT Description(including Proper Sh pping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt jVol 1. rr LU Z 2. W 3. R `+ • `r 01,16 4. 14.Special Handling Instructions and Additional Inform ition 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 resp icts 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 consign ient conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement idei tified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small Suantity generator)is true. GeneratQr's/Offeror's Pdntedrryped Name Signature , / ! Month Day Year 116.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: j# Signature � zz Month Day Year Transporter 2 Printed/Typed Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space � ❑T ❑ ❑ 1 ❑Full Rejectio, ❑ Quantity Type Residue Partial Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number Facilitys Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year E Z 19.Hazardous Waste Report Management Method Codas(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 1 1. 2. 3. 4. l 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. GENERATOR'S INITIAL COPY