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Form Approved.OMB No.2050-0039 Please print or type. 4.Manliest Trackln Number UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 9 J J K WASTE MANIFEST 5.Generator's Name and Malting Address Generator's Site Adailing address) dress(if dlHerenl than m Generator's Phone: U.S. PAID Number 6,Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name 8.Designated Facility Name and Site Address U.S.EPA ID Number Facility's Phone: 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes 9a' No. Type Quantity WI.Nol. HM and Packing Group(if ( O LULU W 2' —-- 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,a d are classified,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. Month Day Year Generalor's/Offeror's Printed/Typed Name Signature 16.International ShipmentsImport to U.S. ExP❑ ort from U.S. Port of entrylexit: F-- ❑ K Transporter signature(far exports only): Dale leaving U.S.: 17.Transporter Acknowledgment of Receipt of Materials Month Day Year Transporter 1 Printedfryped Name Signature a Month Day Year Z Transporter 2 Printed/Typed Name O Signature F 18.Discrepancy 18a,Discrepancy Indication Space ❑ Quantify ElType ❑Residue ❑Partial Rejection Full Rejection Manifest Reference Number: U.S.EPA ID Number 18b.Alternate Facility(or Generator) J U LL Facility's Phone: Month Day Year LOU 18c.Signature of Alternate Facility(or Generator) ZZ 0 19.Hazardous Waste Report Management Melhod Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 1 2. 3• 4• 20,Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manlfest except as noted in Item 18a Month Day Year PrintedlTyped Name Signature EPA Form 8700.22(Rev.12.17) Previous editions'are obsolete. DESIGNATED FACILITY CAP` IF YDI I RECEIVED THIS MANIFEST,YOU HAVE RESPONSIBILITIES UNDER THE e-MANIFEST ACT.SEE INSTRUCTIONS ON REVERSE SIDE.