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Please print or type.(Form designed for use on elite(12-pitch)ty•'ter.) • Form Approved.OMB No.2050-0039 1.Generator IDNumber -2;;�age 1 of 3 Emergency Response Phone 4 Manifest Tracking Number - IIIL UNIFORM HAZARDOUS r9 cy po 9 WASTE MANIFEST ` t.�..`u<; J J K 5.Generators Name and Mailing Address Generator's Site Address(Ndiferent than mailing address) Generators 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 Facility's Phone: as. 91b.U.S.DOT Description(Including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit y)) 13.Waste Codes HM and Packing Group(if an No. Type Quantity Wt./Vol. 1, O 2 2. W 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 Iabeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulators.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 cedly that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)at(b)(if I am a small quantity generator)is true. GeneratorslOReror's Printedrryped Name Signature Month Day Year ri16.International Shipments 1— El import to U.S. ❑Export from U.S. Part ofsoi lezil: Z Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Primed/Typed Name - Sgnal Month Day Year a - . 1 zQ Transporter Printed/Typed Name Signature Month Day Year 1Y H I 18.Discrepancy 1Ba.Discrepancy lndimi Space ❑ Quantity ❑Type ` ue An ❑Partial Rejection ❑Full Rejection EE ❑ a Man ifeslR ere'n'rgNomfl4r: 18b.Alternate Facility Generator) �� Q C U.S.EPA ID Number LOW LL Facility s Phone: du 18c.Signal of Alternate Facility(o(Generator) 4 rAL li.1 IM Month Day Year z y1g.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 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 - PhnteNtyped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous ed8ions are obsolete. GERATOCOPY G�,e-�v Ct st sElgt NEIAL-1(0 -6,s0