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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 Phone4.Manifest Tracking Number WASTE MANIFEST ,'1� ;' JJ K 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 Ubesignaled 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 13.Waste Codes HM and Pecking Group(if any)) No. Type Quantity Wl.Nol. 1. O w 2. 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 all respects in proper condition for transport according to applicable International and national governmental regulations.It 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. Gene rator'slOfteroes Printedfryped Name Signature Month Day Year 16.International Shipments ❑Import to U.S. ❑Expor!from U.S. Port of enlrylexil: ..._— Transporter signature(for exports only): Date leaving U.S.: W 17,Transporter Acknowledgment of Receipt of Materials LU a Transporter 1 Prinledfryped Name Signature Month Day Year 0 CL z Transporter 2 Printedfryped Name Signature Month Day Year 18,Discrepancy 18a.Discrepancy Indication Space F-1 ouanlily Type ❑ ❑ I ❑Full Re' ❑T e Residue Partial Rejection lection Manifest Reference Number: _ 18b,Alternate Facility(or Generator) U.S.EPA ID Number J_ V u- Facility's Phone: Bc.Signature of Alternate Facility(or Generator) Month Day Year a Z eU 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 4 1, 2. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as nded in Ilem 18a Prinledrryped Name Signature Month Day Year EPA Form 8700-22(Rev.12.17) Previous editions are obsolete. DESIGNATED FACILITY COPY IF YOU RECEIVED THIS MANIFEST,YOU HAVE RESPONSIBILITIES UNDER THF e-MANIFEST ACT.SEE INSTRUCTIONS ON REVERSE SIDE.