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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 eta� N1 ¢fest ragkp� �7uWbe5 �+ UNIFORM WASTE MAN HAZARDOUS _ L S w rf ,3 .Fi. ., ; VE�7 UPINI 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 vIN 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 HM and Packing Group (N any)) No. Type Quantity WLNoI. 13. Waste Codes O 2 w . _ . . 3. 4. 14. Special Handling Instructions and Additional Information NINiI - IN IN . . . ,� . ..� . a, > , r . . , , . 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 condifion 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 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. Ge eratoes/Offeror's Printed/Typed Name Signature Month Day Year 16. Intemabonal Shipments - F El import to U.S. ❑ Export from U.S. Port of entry/exit: ? Transporter signature (for exports only): Date leaving U.S.: W 17. Transporter Acknowledgment of Receipt of Materials Transporter i PrintedlTyped Name Signature Month Day Year INN I IN Z Transporter 2 Printedrryped Name Signature Month Day Year ar 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number. 186. Alternate Facility (or Generator) U.S. EPA ID Number ziU <¢ Facility's Phone: w 18c. Signature of Alternate Facility (or Generator) Month Day Year z 19. 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 1 B PnntedlTyped Name Signature Month Day Year EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. GENERATOR'S NEMA,L CGnv