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Please print or type. Form Approved.OMB No.2050-0039 UNIFORM HAZARoous 1•Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST �.j - , 6 F L E 5-Generators Name and Mailing Address Generators Site Address(if different than mailing address) Generators Phone: 6-Transporter 1 Company Name U.S.EPA ID Number T.Transporter 2 Company Name U-S.EPA ID Number 8.Designa led 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,ID Number, 10.Containers11.Total 12,Unit 13-Waste Codes HM and Packing Group(if any)] No. Type quantity Wl.Nol. 1. O F a w z 2, LLI CD 3. 4. 14.Special Handling instructions and Additional Information 15. GENERATOR'SIOFFEROR'5 CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,ani are classified.packaged. marked and tobeledlplacarded,and are in all respects in proper condilion for transport according to applicable intematmnaland national govemmental regulations.K 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)(if I am a small quantity generator)is true- Generator'sfOjferor's PrintedlTyped Name Signature Mth Day Year a 16-Intemational Shipments I— ❑Import to U.S. ❑Export from U.S. Port of entrylexit! = Transporter signature(for exports only): Date leaving U-S-: tic 17.TransporterAcknowledgment of Receipt of Materials LU Transporter 1 PrintedfTyped Name Signature Month Day Year Q IL Transporter 2 Printedfiyped Name Signalure Month Day Year F 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifesl Reference Number: G 18b.Alternate Facility(or Generator) U-S.EPA ID Number J U u- Facility's Phone: W 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) C 1. 2. 3. 4- 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as nded in Item 18a Printedffyped Name Signature Month Day Year EPA Farm 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY