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Please print or type. Form Approved,OMB No.2050-0039 UNIFORM HAZARDOUS e 1 of 3,Emergency Response Phone 4.Manifest nifest Traekin Number 1.Generator ID Number 2.Page g y p g WASTE MANIFEST 1`. SKS 5,Generator's Name and Mailing Address Generator's Site Address(if different than maiting ad ress Generator's Phone 0,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 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(if any}) No. Type Quantity Wt.N01. 13.Waste Codes r„a,y a r Z 2. LU ca 3, 4, 14.Special Handling Instructions and Additional information 15. GENERATOR'SIDFFERDR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping neme,and are clas'sifietl,packaged, marked and laheledlplacarded,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 idenliried in 40 CFR 262.27(a)(i€I am a large quantity generator)or(h)(ifI am a small quantity generator)Is true. Generaior'slOfferor's PrintedlFyped Name Signature Month Day Year A 1t 4 18.Internal Shipments ❑Import to U.S. ❑Export from U.S. l Port of eptrylexit: Transporter signature(for exports only): Date leaving U.S.: jX w 17.TransporterAcknowledgment of Receipt of Materials Transporter 1 PrintedfTyped Name Signature Month Day Year 'O Transporter 2 Printed/Typed Name Signature Month Day Year l t- 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue i j ❑Partial Rejection Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number Facility's Phone: W t8c.Signature of Alternate Facility(or Generator) Month Day Year a z t, 5, 19.Hazardous Waste Repan Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 1. 2. 3, 4. 20.Designated f=acility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1 Be PrintedlTyped Name Signature Month Day Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY