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V/ Please print or type. Form Approved.0 M B No.2050.0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST F L 5.Generator's Name and Mailing Address Generator's 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.EPAID Number 8-Designated Fadlity Name and Site Address U-S.EPA IQ Number Facility's Phone: ga, 91.U.S.110T Description linclud ng Proper Shipping Name,Hazard Class,Ila Number, 10.Containers11.Tote! 12.Unit HM and Padang Group(if any)} 13.Waste Codes No- Type Quantity Wt.Nol. 1, C7 F- W z 2. w +:7 3. 4, 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.packagea, marked and labe€edlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If expo t shipment and I am the Primary -Exporter,i certify that the-contents of this Consignment conform to Me terns of the attached EPA Aoknowledgment oTConsen1. — - -- I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(ill am a small quantity generator)is true. GeneralorwOfferor`s PrintedlTyped Name Signature Month Day Year „,r 16.International Shipments ❑Import to U.S. ❑Exportfrom U.S. Port of entryiexit: Transporter signature[for exports only]: Date leaving U.S.: W 17.Transporte r Acknowledgment of Receipt of Malerials LU Transporter t Printedffyped Name Signature Month Dav Year D ' a aTransporter Printedfryped Name Signature Month Day Year 18.Discrepancy 18&Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑FLA Rejection Manifest Reference Number: N 18b.Alternate Facility(or Generator) U.S.EPA ID Number `v LL Facility's Phone: w 18c-Signature of Alternate Facility(or Generator) Month Day Year !a Z 7n19.Hazardous Waste Report Management Method Codes{r-e-,codes for hazardous waste treatment,disposal,and recycling systems) LLI 0 1 2• 3. 4. 20-Designated Facility Owner or.Operator:Certification of receipt of hazardous materials covered by the manifest except as n ted in Item 1 Be Printedfryped Name Signature Month Day Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete- DESIGNATED FACILITYTO GENERATOR