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Please print or type. Form Approved . OMB No, 2050-0039 UNIFORM HAZARDOUS 1 . Generator ID Number 2. Page 1 of 3 Emergency Response Phone 4. Manifest Tracking Number I' JJK WASTE MANIFESTIf 5, Generators Name and Mailing Address Generators Site Address (if different than mailing address) If Generators Phone: . f 6. Transporter 1 Company Name U .S. EPA ID Number el 1 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: ^sir . 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 WLNoI13. Waste Codes . f 4 Z 2. w O 3. 4. 14. Special Handling Instructions and Additional Information 3 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 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. 1 certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (ifl am a small quantity generator) is true. Generator's/Offeror's PrintedlTyped Name Signature s ' Month Day Year I y I 16. International Shipments F El import to U .S. El Export from U.S. Port of entry/exit: K Transporter signature (for exports only): IV leaving U.S. : W 17. Transporter Acknowledgment of Receipt of Materials LU Transporter 1 Printed/Typed Name Signature Month Day Year O Z Transporter 2 PrintedlTyped Name Signatures Month Day Year t- 18. Discrepancy BOB 18a. Discrepancy Indication Space ❑ Quantity Type ❑ ❑ Partial Re ❑ Full Re' ❑ T e Residue Rejection lection Manifest Reference Number: >� 18b. Alternate Facility (or Generator) U.S . EPA ID Number �r LLM V Facility's Phone : 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 18a Printedrryped Name Signature Month Day Year EPA Form 8700-22 ( Rev, 12- 17) Previous editions are obsolete . GENERATOR' S INITIAL COPS'