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1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 13. Waste Codes Type I 2. 3. 4. 14. Special Handling Instructions and Additional Information 16. International Shipments Transporter 2 Printed/Typed Name D Partial Rejection□ Residue Manifest Reference Number: . U.S. EPAID Number18b. Alternate Facility (or Generator) Day Year 3.4.1. Day Year ERA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. Generator's Phone:_________ 6. Transporter 1 Company Name Port of entry/exit: Date leaving U.S.: 11. Total Quantity 12. Unit WtA/ol. 9a. HM od O DU LU 2 LU e § o 5 Q LU 3 z e co LU Q □ Type □ Full Rejection z a: O Q. cn z s □ Import to U.S. Transporter signature (for exports only): 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 PrintedFTyped Name Facility's Phone:_____________________ 18c. Signature of Alternate Facility (or Generator) 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 18. Discrepancy 18a. Discrepancy Indication Space 10. Containers No. Please print or type._______ UNIFORM HAZARDOUS WASTE MANIFEST 5. Generators Name and Mailing Address 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) T ~ ~ Facility's Phone: 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, and Packing Group (if any)) T U.S EPAID Number J______ U.S. EPA ID Number J______ U.S. EPAID Number 7. Transporter 2 Company Name 8. Designated Facility Name and Site Address 15. GENERATOR’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 minimizabon 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/Offeroris Printed/Typed Name Signature I □ Export from U.S. Signature J__ Signature I___ Month I I GENERATOR’S INITIAL COPY Year I i Year Month I □ Quantity ___________Form Approved. OMB No. 2050-0039 4. Manifest Tracking Number _________303337542 SKS Generator's Site Address (if different than mailing address) Day Month Day I f I I » Month