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Please print or type. Form Approved. OMB No. 2050-0039 1 Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4 M i g tl)ra g,Ngwb L , UNIFORM HAZARDOUS a�an VES WASTE MANIFEST - - - . . t U �, , i u ) 4.0 ,rG V 5. Generators Name and Mailing Address _ Generators Site Address if different than mailing address) Generators Phone: 6. Transporter 1 Company Name U.S. EPA ID Number 7. Transporter Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address U.S. EPA ID Number Facility's Phone: - - - - - - 9, 91o. 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 Quanfity Wt/vol. C O a C w z 2. w U 3. 4. 14. Special Handling Instructions and Addl onal Information - 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 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 EPAAcknowledgment of Consent I certify that the waste minimization statement identified in 40 CFR 26227(a) (if I am a large quantity generator) or (b) ('ff I am a small quantity generator) is We. GeneratoeslOfferoes PrintedlTyped Name Signature Month Day Year 16. International Shipments F 1:1 Import to U.S. El Export: from U.S. Port of entrylexit ? Transporter signature (for exports only): Date leaving U.S.: W 17. TransporterAclmowledgment of Receipt of Materials _ Transporter 1 Prmted/Typed Name Signature Month Day Year O CL 17 QTransporter2 PnntedlTyped Name Signature Mont Day Year K r .p 18. Discrepancy 1 Ba. Discrepancy Indication Space ❑ Quantity ❑ ❑ Full Rejection El Residue Partial Rejection 1 Manifest Reference Number. F 18b. Alternate Facility (or Generator) U.S. EPA ID Number zi U uQ- Facility's Phone: w 18c. Signature of Alternate Facility (or Generator) Month Day Year r Q Z US19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 1 . 2. 3. 4. 20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item IBe Printed/Typed Name Signature Month Day Year EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. GENEi<;fbTOR'S 6'NMAL COFx.®