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Please print or type. JUNIFORM HAZARDOUS 1. Generator ID Number I WASTE MANIFEST 5. Generator's Name and Mailing Address Generator's Phone 2. Page 1 of I 3. Emergency Response Phone I 4. N F Generator's Site Address (if different than mailin Form Approved. OMB No. 2050-0( 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 ,'�• 7: F1F�s!_j4 i 1_l-,4t'<'L i L Facilitv's Phone: SKS AWitCAt-9 ak!, 1 9a HM 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, ` and Packing Group (if any)) 10. Containers 11. Total Quantity 12. Unit Wt.Nol. 13. Waste Codes No. Type 1. 2. 3. 4. 14.opeaainanuung msrrucuons anu Huamonaiimormauon a dt it t. aJ off':' "ik'y00--4t°`i e J 0-- 'J rt -i trrJ 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. Generatos/Offeror's Printed/Typed Name Signature Month Day Year n, 16. International Shipments 1- ❑ Import to U.S. ❑ Export from U.S. Port of entrylexit: z Transporter signature (for exports only): Date leaving U.S.: of 17. Transporter Acknowledgment of Receipt of Materials LU 1 Transporter 1 Printed/Typed Name Signature Month Day Year a t I id. uiscrepancy I18a. Discrepancy Indication Space ❑ Quantity - 18b. Alternate Facility (or Generator) J U U Facility's Phone: w 18c. Signature of Alternate Facility (or Generator) Q Z G9 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) G 1. 2. 3. 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 Dav Year ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejectiop Manifest Reference Number: U.S. EPA ID Number 4. Day Year EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. GENERATOR'S INITIAL COP)