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Form Approved.OMB No.2050-0039 ase print or type.(Form des � c- _ ==- e = 12-pitch)typewriter.) - 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number �� UNIFORM HAZARDOUS - J WASTE MANIFEST 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Generator's Phone: U.S.EPA ID Number 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 Facility's Phone: ga. 9b.U S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers it.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wtivol. C D L L 2.3. E4. _ 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 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 terns 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 we. Month Day Year GeneratorslOfteror's PrintedTyped Name Signature rj 16.Intemational Shipments Import to U.S. El Export from U.S. Port of entry/exit: F- Date leaving U.S.: Z Transporter signature(for exports only): W 17.Transporter Acknowledgment of Receipt of Materials Month Day Year Transporter 1 Phntedrryped Name Signature O a Month Day Year QTransporter 2 Prinledrryped Name Signature 18.Discrepancy 1 Ba.Discrepancy Indication Space 0 Quantity �TYPe ❑Residue ❑Partial Rejection El Full Rejection Manifest Reference Number: U.S.EPA ID Number 18b.Altemate Facility(or Generator) J U ua Facility's Phone: Month Day Year OO 18c.Signature of Allemate Facility(or Generator) L a Z N 19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment.disposal,and recycling systems) w 1 2. 3. 4. D ' 20.Designa1 ted Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Month Day Year Printed/Typed Name Signature EPA Form 8700-22(Rev.3-05) Previous editions are obsolete.