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0 0 5 3 2 8 8 0 7 S K S Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST 005328807 5 KS 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) Generator's Phone: 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 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Grou (if any)) No. Type Quantity Wt.Nol. o �. z 2. W 3. 4. 14.Special Handling Instructions and Additional Information 15. GENERATOR'S/OFFEROR'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 EPA Acknowledgment 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 (ti I am a small quantity generator is true. Generatosl eror's Pt ted(Typed Name Signature Month Day Year *1 tnz L k ; (va 21 —J 16.InternatioWShilprrianti Z ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printe yped Name Signature Month Day Year N osh u Q U I q 121 QTransporter 2 PrintedlTyped Name Sign tur Month Day Year r f1061 1712,1 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity El Type ❑Residue ❑Partial Rejection El Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U rai Facility's Phone: w 18c.Signature of Altemate Facility(or Generator) Month Day Year Q Z N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) G 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 Printed/Typed Name / p Signature Month Day Year 1_71 EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) _ J