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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) .4 .. Form Approved.OMB No.2050.0039 UNIFORM HAZARDOUS 1.Genem ar lO Number - 2.Peg'1 of 3 Emapitency Response Ptade 4 Ma fest Tmcki g Number WASTE MANIFEST 1 3 6 JJ K „ "' 5.Generators Name and Mailing Address Gererebrs S'de A,,ri j,,Vm rent than mailing address) IY Generators Phone: US.EPA ID Number 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name S.Designated Facility Name and Site Address U.S.EPA ID Number Facility's Phone: - 9a. 9b.U.S.DOT Description(inducing Paper Shipping Name,Hazy d Clens,ID Number, 10.Containers 11.Tatsl 12.Unit 13.Waste Codes HM and Packing Group if any)) No. Type Quantity WWoI. O z 2. c9 c9 3. n 14.Special Handling Instructions and Additional Information 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby dedam that the content of this consignment are fulty and accurately described above by the proper shipping name,aM are classified,packaged. marked and labeledlplacarded,and are in all respects in proper condtion for transport according to applicable international and nabanal governmental regulators.If export shipment and 1 am the Primary Exporter,I decoy that the contents of this consignment conform to the terms of the attached EPAAcknowledgnili of Garment. I Unify That the waste minimization statement identified in 40 CFR 26217(a)(ffI am a large quantity gene2mr)or(b)(aI am a small quantity generator)is tore. Signature Month Day Year Generatofelof ears Pirm Typed Name - 16.Intema6onal Shipments ❑Import to U.S. ❑Expad from U.S. Port of enr ytexit = Transporter signature(for export onty): Date leaving U.S.: 17.Transporter AclavoWedgmeMof Receipt OfMatedat Transporter l Printedfryped Name Signature Monts Dayt Year TreniPorter 2 FdntrlRyped Name Signature-' Day Year K r .a 18.Discrepancy Ise.Discrepancy Indication Spam ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Mani Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA IO Number J U tai Facility's Phone: W 18,Signature of Alternate Facility(or Generator) Month Day Year 6 Z v0—i 19.Hazardous Waste Report Management Mebwd Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) D 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 Prime yped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COP'