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Please tint or type.Ypa. Formi4pprnvsd.OMB No.2050-0039 UNIFORM HAZARDOUS rGene,at.,ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST Nk �" V F L E 5.Generator's Name and Mailing Address Generalor s SRO Address(if different than mailing address)y Genaratats Phone: 6-Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U-S-EPA ID Number i 8.Designated Faelllly Name and Site Address U.S.EPA ID Number Facilil's Phone: 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) 13 Waste Codes No. Type Quantity Wt.Nol. 1. O z w O 1 3 4 14,Special Handling Instructions and Additional Information r , 15. GENERATOR'SIOFFEROR'S CERTIFICATION. I hereby declare that the contents of this consignmentare 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 If export shipment and I am the Primary Exporter,l certify that the contents of this 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)(if t am a small quantity generator)is true. Generator's/Offeror's Printed/Typed Name Signature Month Day Year J 16.Inlemalbnal ShlpmenN ❑Import to U.S. ❑Export from U.S. Port of entry/exit: ? Transporter signature(for exports only)_ Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials LLJ 1 ransporter 1 PrintedfTyped Name Signature Month Day Year O z iransporter2Nrintedr-lypedName Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type Residue ❑Partial Rejection ❑Full Rejection ❑ Manifest Referance Number: 18b.Alternate Facility(or Generator) U_S,EPA ID Number J t..) 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.e.,codes for hazardous waste treatment,disposal,and recycling systems) LU i 1, 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 PdntedlTyped Name Signature Monlh Day Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY