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Please print or type. Form Approved.OMB No.2050-0039 UNIFORM FfA7ARa0U5 1.Generalor ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number J J K WASTE MANIFEST 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.EPA ID Number S.Designated Facility Name and Site Address U.S.EPA ID Number Facility's Phone: ga 91.U.S.00T Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) No. Type Quantity Wt.lVol. 13.Waste Codes t. z 2. i I su I 3. 1II 4. 14,Special Handling Instructions and Additional Information 15. GENERATOR'S10FFEROR'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 labeled7piacarded,and are in all respects in proper condition for transport according to applicable internaVonaland national governmental regulations.If export shipment and I am the Primary Exporler,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)(ifI am a small quantity generator)is true. Generator's*fferor's PrintedlTyped Name Signature Month Day Year 16.International Shipments Ill- ❑Impart to U.S. ❑Expel from U.S. Port of entrylexii: Z— Transporter signature(for exports on€y): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials � Transporter 1 PrintedlTyped Name Signature Month Day Year O a Z Transporter 2 Printedlrryped Name Signature Month Day Year H 18-Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type j I Residue ❑Partial Re ection Full Rejection Manifest Reference Number: >- 18b,Alternate Facility(or Generator) U.S.EPA ID Number J U LL Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year Q z19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 1 2. 3. Notice: State of California requires generator to photocopy and mail to 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item Ill With 30 days: Printed/Typed Name Signature P.0 Box 40011 1 ar Sacramento, CA 95812-0400 EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY