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Please print or type. Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1,Generale,Ill Number 2,Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number SKS e WASTE MANIFEST �- V K V 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Generator's Phbne: 6.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.Tatat 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. l w " Z 2. LL1 C7 3. 4. i 14.Special 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 labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and nalionai 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 EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(x)(if I am a large quantity generator)or(h)(if I am a small quantity generator)is true. Generator eror's Printed ,ped Name . Signature Month Day Year yr t 16.international Shipments H ❑Import to U.S. ' ❑Export from U.S. Port of entry/exit: ? Transporter signature(for exports only): Hate leaving U.S.: EW 17.Transporter Acknowledgment of Receipt of Mi Transporter 1 PrintedFyped Name Signature Month Day YeaF D CL Z Transporter 2 PrintedlTyped Name Signature I Month Day Year R� 18.Discrepancy 18a.Discrepancy Indicatton Space ❑ Quantity 171 Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number U Facility's Phone: � - 1 18c.Signature of Alternate Facility(or Generator} Monih Day Year Q z CD m 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) � 1. T. 3, 4, 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1 Ba Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY