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r Form Approved.OMB No.2050.0039 Please print or type. UNIFORM MAZARDflUS t.Generator ID Number 2-Page i of 1Emergency Response Phone 4.Manliest Tracking Number J J K r . , WASTE MANIFEST 5 Generator's Name and Mailing Address Generators Site Address(if different than mailing address) Generator's Phone: 6.Transporter 1 Company Name 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 �If�lrr�r3r_'i•I ffar;_r 300 Iti 1135 F";iIj Facility�s Phone: ga gb.U.S.OOT Description{including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12,Unit 13,Waste Codes HIM end Packing Group(if any)) No. Type Quantity WLNcl. V IF,l.Jt.2111i;'I'_!il z 2. LU 3 t 14.Spabal Handling Instructions and Additional Informalicn tI.I `'t1i 'Ii '''ill - 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and aoeufately described above by the proper shipping name,Ord are classified.packaged, marked and labeledlplacarded,and are in ail respects in proper condition for transport according to applicable International and national governmental regulations.Irexport shipment and I am the Primary Exporter,I 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 26227(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generator'slOfferees Printed/Typed Name Signature Month Day Year 16.International Shipments ❑import to U.S. ❑Export from U.S. Port of anlrylexil: _ z Transporter signature(for experts only), Date leaving U.S.: W 17.TransporterAcknaNedgmentof Receipt ofMaterials w Month Day Year a Transporter 1 PrinteOyped Name Signature f] Transporter 2 PrintedlTyped Name Signature Month Day Year h 18,Discrepancy i8a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rojection Manifest Reference Number; 18b.Alternate Facility(or Generator) U.S.EPA ID Number U U- Facility's Phone: LU 18c.Signature of Allemate Facility(or Generator) IAonth Day Year a Z N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste Treatment,disposal,and recycling systems) G 1. 2. 3. 4. %i 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by The manlest except as noted In Item 18a riteNTyped Name Signature a ;'f Month Day Yeari EPA Form 8700-22(Rev.12-17) Previous editions are obsolete, GENERATOR'S INITIAL COPY