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Please print or type. Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1 Generator ID Number Z Page 1 of 3,Emergency Response Phone 4,Manifest Tracking Number WASTE MANIFEST TJJ K 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) i Generalor's Phone: 6,Transporter 1 Company Name U.S.EPA ID Number 7.Transporier2 Company Name U.S.EPA ID Number 0.Designated Facility Name and Sile Address U.S.EPA ID Number Facility's Phone: vga, %,U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total flWt�.Nol. HM and Packing Group(if any)) 13.Waste Codes No. Type Quantity 0 _3. �4. 14.Special Handling Instructions and Additional Information 15, GENER ATOR'SIOFFEROR'S CERTIFICATION: I hereby declare(hal the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labelediplacarded,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(hat the contents of(his consignment conform to the terms of the attached EPAAcknowledgment 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)(fit am a small quantity generator)is true. Generalor'sl0lreror's Printed/Typed Name Signature Month Day Year i6.llnternational Shipments r ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Transporter signature(for exports only): Date leaving U.S.: 17.Transporter Acknowledgmen(of Receipt of Materials Lu Transporter 1 PrintedlTyped Name Signature Month Day Year 0 ts. _ Transporter 2 Printed/Typed Name Signature Month Day Year r 18.Discrepancy 18a.Discrepancy Indication Space ❑ quantity ❑Type ❑Residue ❑Partial Rejec(lon ❑Full Rejection Manifest Reference Number: _18b.Allnrnate Facility(or Generator) U.S.EPA ID Number ,rP Facility's Phone: 18c.Signalure 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) LLIi 1 ____._�..___� 2. 3. -7- 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrintedlTyped 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 TIME e.-MANIFEST ACT,SEL IN9TRUCTIOMS ON REVERSE SIDE.