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Please print or type. Faun Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1,Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4 Manifest Tracking Number WASTE MANIFEST JJK 5.Generator's Name and Mailing Address Generator's Site Address(ff different than mailing address) Generator's Phone: - 6.Transporter 1 Company Name U.S.EPA ID Number V. 7.Transporter2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA tD Number Facilii '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(if any)) No. Type Quantity yyf,p/a, 13.Waste Codes i. faY Z 2. uu O 3. 4. 14.Special Handling Instructions and Additional Information 15. GENERATOR'S10FFEROR'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 intemationaland 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 EPAAcknowledgment 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)(ifI am a small quantity generator)is true. Generator's/Offeroes Pdnted/Typed Name Signature Month Day Year 16.International Shipments H ❑Import to U.S. ❑Exportfrom U.S. Port of entry/exit Transporter signature(for exports only): Dale leaving U.S.: w 17.Transporter Acknowledgment of Receipt of Materials t2 Transporter 1 PrintedfTyped Name Signature Month Day Year O Z Transporter 2 Printedfryped Name Signature Month Da Year 9 y 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 U LLa. Facility's Phone: GENERATOR In 18c.Signature of Alternate Facility(or Generator) Month Day Year 0 It is your responsibility to make a co 07 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous m copy LU «, 2 of this Generator's Initial Capy"and mail it within 30 days,10-- 20.Designated Facility Owner or Operator;Certification of receipt of hazardous mates DTSC Generator Manifests Printed(Typed Name P.O. Box 400 Month Day Year Sacramento, CA 95812-0400 EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY