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Please print or type. Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1 Generator ID Number 2.Page l of 3 Emergency Response Phone 4.Manifest Tracking Number (�[[� WASTE MANIFEST ,. .. .. [� �.`.: V IAV 5.Generator's Name and Mating Address Generator's Site Address(if different than mailing-address) Generator's Phone: 6.Transporter f Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.FPA iC Number S.Designated Facility Name and Site Address U.S.EPA ID Number Facility's Phone: 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,le Number, 10.Containers 11.Total 12,Unit HM and Packing Group(if any)) No. Type Quantity Wt.Nal. 13.Waste Codes I1J L 2. 3. 4. 14.Special Handling Instructions and Additional Information Irl.' 4 f- i.-'._ r4 Y'nkl.'t, Y'��f 0, gl,!11,r' . ' I 15. GENERATDR'SlDFFERDR'S CrRTlFICAtIDN: I hereby declare that the conien Ls of This corisignment are dully and accurately described above by the proper shipping name,and are classified,packaged, marked and labeledlplacarded,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 262.27(a)(if I am a large quantity generator)or(b)(if i am a small quantity generator)is true. Generatorsl0f{erof s PrinledfFyped Name Signature) Month Day Year 16.International Shipments ❑Import to US. ❑Export from U.S. Part of enlrylexit: z Transporter signature(for exports only): Dale leaving U.S.: 17,Transporter Acknowledgment of Receipt of Materials Transporter 1 PrintedlTyped Name Signature Month Day Year O o.. Z Transporter 2 PdntedlTyped Name Signature Month Day Year h 18.Discrepancy 18a-Discrepancy Indication Space ❑ Quantity El Type 11 Residue ❑Partial Rejection ❑Full Rejection i Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA iD Number U !¢r. Facility's Phone: W 1 Sc.Signature of Alternate Facility(or Generator) Month Day Year a Z F, 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 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 18a Pfintedrfyped Name Signalure Month Day Year EPA Farm 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY