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:P.,Igase print or type.(Poon designed for use on elite(12-pitch)typewriter) • Form Approved.OMB No.2056-0039 UNIFORM HAZARDOUS 1.Generator IDNumber -_ 1.rage 1 of 3 Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST JJK v C 5 Generators Name and Mailing Address Generator's Site Address Of different than mailing address) Generator's Phone: - - 6.Transporter 1 Gompany Name U.S.EPA IDNumber 7.Transporter 2 Company Name U.S.EPAID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number Facility's Phone: - r 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) No. Type Quantity Wtdvol. 13.Waste Codes of 1. LU 2. Lid 0 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 labeledlplacarded,and are in all respects in proper condition for transport according 0 applicable intemationaland 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 minimization 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. GenenatoeslOfferors PnntedlTyped Name Signature Month Day Year —s 16.International Shipments i ❑Impart to U.S. ❑Export from U.S. Pori ofentry/exit: Transporter signature(for exports only): Dale leaving U.S.: w 17.TrenspoderAcknowledgment of Receipt of Materials Transporter 1 PdntedlTyped Name Signature O Manch Day Year tq Z Transporter 2 Printedr-yped Name Signature Month Day Year I- 18.Discrepancy - 18a.Discrepancy Indication Space Quantity ❑ a a.Type ❑partial Rejection ❑Full Rejection El Manifest Reference Number. 18b.Alternate Facility(or Generator) M' i L 17 U.S.EPA ID Number J U ra Facility's Phone: �94MCNfb pNTA1F}EP LTH w 18c.Signature of Alternate Facility(or Generator) /,ER 'iEJ^ Month Day Year Q Z 19.HazallousWaste Report Management Method Codes(i.e.,codes for hazardous waste basement,disposal,and recycling systems) 1 2 3. 4. 20.Designated Facility Owner or Operator:Cerfification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrinxKV yped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY