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Piease print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZAR!]OUS 1.Generator ID Number 2.Page 1 of 3 Emergency Response Phone A Manifest Tracking Number. WASTE MANIFEST J 5 Generators Name and Mailing Address Generators Site Address(if different than mailing address) Generator's Phone: 6.Transporter 1 Company Name 7s—EPA–ID Number 7,Transporter 2 Company Name U.S.EPA ID Number. . .. 8.Designated Facility Name and Site Address U.S.EPA 10 Number Facility`s Phone:: ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number 10,Containers 11.Total Q.Unit 13,Waste Codes NM and Packing Gra,p{if ani No. Type Quantity WLNdi O 2 t. .- LLE 0 :: .: �. ... 3. 4. E r 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 labeled/placarded,and are in all respects in proper condition for transport according to applicable internalional 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 Cl 26227(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generator's/Offerors Printed/Typed Name Signature;- Month pay Year J 16.International Shipments ❑Import to U.S. ❑Export from U.S. Port of entrylexit: Transporter signal(for exports only): Date leaving U.S.: 17.Transporter Acknowledgment of Receipt of Materials LU Transporter 1 PrintedlTyped Name Signature Month Day Year 0 c�. QTransporter 2 Printed/Typed Name Signature Month Day Year F-^ 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity F1 Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 181 Alternate Facility(or Generator) U.S.EPA ID Number e� Facility's Phone: U" 18c.Signature of Alternate Facility(or Generator) Month Day Year a 19.Hazardous Waste Report Management Method Codes("e.,codes for hazardous waste treatment,disposal,and recycling systems) LU 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 Printedflypad Name Signature Month Day Year FPA Form 8700-22(Rev.3-05) Previous editions are obsolete. ENERATOR'S INITIAL COPY