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1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone SKS -«*■ U.S. EPA ID Number 7. Transporter 2 Company Name 8. Designated Facility Name and Site Address Facility's Phone: 13. Waste Codes Type 2. 3. 4. 4 14. Special Handling Instructions and Additional Information 16. International Shipments O Export from U.S.;ort to U.S. Year Transporter 2 Printed/Typed Name O Full Rejection Manifest Reference Number. U.S. EPA ID Number18b. Alternate Facility (or Generator) Year 4.2.3. Day EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. I Port of entry/exit Date leaving U.S.: 12. Unit Wt./Vol. 9a. HIM 11. Total Quantity tx o § LU Z LU e Olype □ Partial Rejection § o 2 a LU 5 z o cn LU a EZI Residue Month I - Month I Month I 18. Discrepancy 18a. Discrepancy Indication Space i- z or LU o CL COz 2 13. Containers No. □ lmp< Transporter signature (lor exports only): 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name 15. SENERATOR’S/OFFEROR'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. 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. Generator's/Offeror's Printed/Typed Name Signature 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 Please print or type._______ UNIFORM HAZARDOUS WASTE MANIFEST 5. Generator's Name and Mailing Address Facility's Phone: 18c. Signature of Alternate Facility (or Generator) Generator's Phone:________ 6. Transporter 1 Company Name 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, and Packing Group (if any)) U.S. EPAID Number ]_______ U.S. EPA ID Number 19. Hazardous Waste Report Management Method Codes (i.e„ codes for hazardous waste treatment, disposal, and recycling systems) T Signature 1L- Signature J___ Day I Month Day Year I | I GENERATOR’S INITIAL COPY Month Day Year I I I ____________Form Approved. QMS No, 2050-0039 4. Manifest Tracking Number Generator's Site Address (if different than mailing address) Year I □ Quantity Day ]_ Day I