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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 FfUNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST .. JJ K 5.Generators 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 Nunber �'.�:?i_�'•`.i :;3ti:i,�i;:a+a.:i'e13;.: �::�1i�:F:�. .., .. , 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('d any)) No. Type Quantity Wt.Nol. 1. Q w z 2. w 0 3. 4. 14.Special Hardling Instructions and Additional Information :+.14 iet :.4 'A 1,4 `f'l �s. i fr:f}kr'�yL•ar ` ?g 4 tip-�'lti+sf� atx�.+ 't'U:i.)ti �)I:« rr'Pr. 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 labelediplacarded,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 26227(a)('d I am a large quantity generator)or(b)(d I am a small quantity generator)is true. Generator'slOfieror's Printed/Typed Name Signature Month Day Year 16.International Shipments F- ❑Import to U.S. Export from U.S. Port of entry/exit: Transporter signature(for exports only): Date leaving U.S.: Or 17.TransporterAcknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day Year O CL co Transporter 2 Phntedrfyped Name Signature AlorrUr Day Year Q 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 J_ Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatinent,dis)osal,and recycling systems) i 1. 2. 3. 4. 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in ftem 18a Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY