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Please print or type. y Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST 0 P ) 770 !" 18 JJ K 5.Generators Name and Mailing Address Generators Site Address{if different than mailing address) r. , Generators Phone: 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Des;gnaled Fablily Name and Site Address U.S.EPA ID Number Facility's Phone: 9a, 9b,U.S.DOT Description(including Proper Shipping Name,Hazard Class.10 Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) 13.waste Codes No. Type Quangty WI.NOI. 1." f!C 0 0.� i 2. w c� 3. 4. 14.Special Handling Instructions and Additional Information `) 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 fabeledlplacarded,and are In all respects in proper condillon for transport according to applicable internalionaland national governmental regulations.If export shipment and I am the Primary Exporter,I Belly 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)(III am a small quantity generator)is true, Generator'slOfferor's Printed/Typed Name Signature Month Day Year ' f 16.Intematfonal SKpmenls ❑ Import to U.S. ❑Exporl from U,S. Port of enlrylexit: Transporter signature(for exports only): Date leaving U.S.: IX W 17.TransporterAcknowfedgment of Receipt of Materials t- Transporter 1 Printed(Typed Name Si nature O 9 Month Day Year CL zTransporter 2 Prinledffyped Name Signature Month Day Year F- 18,Discrepancy 18a.Discrepancy Indication Space ❑ QuantityType Residue r ❑Full Rejection ❑ Yp ❑ ❑Partial Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA tD Number U L Facility's Phone: W 18c.Signature of Altemate Facility(or Generator) Month Day Ysar a z a519.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LU 1 2. 3. 4. 20.Oasignated Facility Owner or Operalor.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrintedlTyped Name Signalura Month Day Year. EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. .'' GENERATIl INITIAL CdPY