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Please print or type. Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1 Generator ID Number TP31 e 1 of 3.Emergency Response Phone 4.Manifest7racking Number WASTE MANIFEST y ,_f F L E 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Generators Phone: 6.Transporter 1 Company Nairw 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 FacUity's Phone: 9a, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HIM and Packing Group(if any)) 13 Waste Codes No. Type Quantity WtNol. 1 ' o I w z 2 w -. . c9 _ I f 4 14.Special Handling Instructions and Additional Information i 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'm proper condition for transport according to applicable internationaland 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)(ifI am a small quantity generator)is true. Generator's/Offeror's Prtnted/Typed Name Signature Month Day Year 16.Internntlonal Shipments H ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Z Transporter signatufe(for exports only): Date leaving U-S.: W 17.Transporter Acknowledgment of Receipt of Materials LLI Transporter 1 Prinwd7yped Name Signature Month Day Year O a , Z Transporter 2 Printed/I yped Name Signature Month Day Year H 18.Discrepancy 18a.Discrepancy Indication Space El Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 181b.Alternate Facility(or Generator) U.S.EPA ID Number J U LL Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z N19.Hazardous Waste Report Management Method Codes(i.a,codes for hazardous waste treatment,disposal,and recycling systems) p t• 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.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY