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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 JJK 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 8. Designated Facility Name and Site Address U.S. EPA ID Number Facility's Phone: ga. 9b. U.S. DOT 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,Nol, 13, Waste Codes t O Z 2, UJ c� 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, packaged, marked and labeled/placarded, and are in ail 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 EPAAcknowledgment of Consent. 1 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'slOfferor's PrintedlTyped Name Signature_- ., Month Day Year J 16, International Shipments F- ❑ import to U.S. ❑ Export from U.S. Port of entry/exit: Z Transporter signature (for exports only): Date leaving U.S.: W 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day Year O CL z¢ Transporter 2 Printed/Typed Name `Signature Month Day Year 18. Discrepancy 18a, Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residuej ❑ f ❑ Partial Rejection Full Rejection Manifest Reference Number: tr— 18b. Alternate Facility (or Generator) U.S. EPA ID Number J U ILL. FacilitysPhone: w 18c. Signature of Alternate Facility (or Generator) Month Day Year Q Z 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) UJI 0 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 Signature Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete.