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(Form designed for use on els(12-p,tch)typewriter.) Form Approved.OMB No.2050-0039 ,rtM HAZARDOUS 1.Generator ID N.,-: 2.Page 1 of 3.Emergency Response Phone 4.Manffest Tracking Number 1NASTE MANIFESTOF`20888 s KS 5.Generators Name and Mailing Add2ss Generator's 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 Facility's Phone: 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)) 13.Waste Codes No. Type Quantity Wt.Nol. 1. O a -- z 2. w O 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,arca are classified,packaged, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and 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. GeneratoeslOfferoes PnntedlTyped Name Signature Month Day Year J 16.International Shipments Z ❑Import to U.S. El Export from U.S. Port of entry/exit: Transporter signature(for exports only): Date leaving U.S.: cl: 17.Transporter Acknowledgment of Receipt of Materials LU Transporter 1 Printed/Typed Name Signa re Month Day Year CO Q Transporter 2 Printedffyped Name Signature Month Day Year tr 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quant ❑Residue ❑Full Rejection ty El ❑Partial Rejection j Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J V uQ Facility's Phone: w 18c.Signature of Attemate Facility(or Generator) Month Day Year Q Z N 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 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 Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. E P 1 E R A T v r,S i N 7!_ `'1°Y