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Please print or type, 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 T JJ�[r` 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 t; a' 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;, 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quanilty, ; Wt.Nol. 1, w w 2, 3. d. 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 classilled,packaged, marked and labeled/placarded,and are In all 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 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. Generators/Offerors Printed/Typed NameSignature Month Day Year _j 16.International Shipments ❑Import to U.S. ❑Export from U.S. Port o(enlrylexit: ? Transporter signature(for exports only): Dale leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials I& Transporter 1 Printed/Typed Name Signature Month Day Year ZTransporter 2 Printed/Typed Name Signature Month Day Year H 18.Discrepancy 18a,Discrepancy Indication Space ❑ Quantity ❑Type ❑ J ❑Full Rejection ❑Residue Partial Rejection I Manifest Reference Number: 18b,Alternate Facility(or Generator) U.S.EPA ID Number V Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 1. 2. 3. 4. LLI �I 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as no(ed in Item 18a PrintedlTyped Name i Signature Month Day Year EPA Form 8700-22(Rev.12.17) Previous editions are obsolete. DESIGNATED FACILITY IF YOU RECEIVED THUS MANIFEST,YOU HAVE RESPONSIBILITIES UNDER THE e-MANIFEST ACT.SEG INSTRUCTIONS ON REVERSE SIDE,