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Please print or type, Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1 enermor ID Number 2,Pae 1 of 3.E�{er 9rpyyRes p....Phone r A.Manifest Tracking Number WASTE MANIFEST s y/ r ,.`r F1' � f� 024054071 J J K 5.Generator's No" n Mallin�Ad cess ; 1 f� ., anera ds Site Address(if different than alhn"ddress) + J � � C +t �' } } Generator's Phan t*r ! T3 :_ ,.3 6.Transporter 1 Company Name-, ;' U.S.f A ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address i , i�.� r Y U.S.EPA 10 Number subafik_ � 1 � 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(ff any)) No. Type Quantity Wt.Nol. o w Z 2. w 3. 4- 14.Specie Handling Instructions and Additional 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 labelediplacarded,and are in all respects in proper condition for transport according 10 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 ceaffy 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. Generalorsl0fferors F;rintedrryped arae Signature- Mooth Day Year 16.International Shipments ❑Import to U.S. ❑Export from U.S. Port of entrylexit: ? Transporter signature(for exports only): Date leaving U.S.: W 17,Transporter AcknowledgmentofReceiptofMaterials Transporter 1 PrintedlTyped Name Signature 4 Month_ Day Year 4 f Transporter 2 Printedlfyped Name Signature Month Day Year H 18.Discrepancy f8a.Discrepancy Indication Space ❑ Quantity ❑T e yp El Residue ❑Partial Rejection ❑Fu11 Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J 0 Faclity'sPhone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year a z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) p 1. 2. 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 Day Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete, GENERATOR'S INITIAL COPY.