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Please print or type. (Forth designed for use on elite (12 -pitch) typewriter.) Form Approved. OMB No. 2050-0039 EPA Form 0700.22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY'S COPY UNIFORM HAZARDOUS 1. Generator ID Number z. Pagel of 3. Emergency Response Phone 4.Manifesamcking Number WASTE MANIFEST �( JJ K 5. Generators Name and Mailing Address Generators Site Address (if di&rent than mmling address) Genemloes Phone: 6. Transporter 1 Company Name U.S. EPA ID Number 7. Transporter 2 Company Name U.S. EPAID Number 8, Designated Facility Name and Site Address U.S. EPAID Number Facility's Phone: go. 91b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Tola1 12. Uril 13. WaOeCodea No. Type HM and Packing Group(dany)) QuarNgr WINO. , Q K 1 - Z 2. 1 i 3. 4 14. Special Handbng InsWdbgs and Addilione gbmraiion 15. GENERATOWS10FFEROR'S CEKnFICATION: I hereby declare that the contents uflhis consignment am fully and acaurately described above by the proper shipping name, and are classified, packaged, marked and lahe!aplacorded, and am in all respects N proper condition for eanspon according to applicable intemabonaland rational governmental regulations. if export shipment and I am the Primary Exporter, I cortify that the contents of thlsconsignment conlomt to the terms of the attached EPAA6"Medgment of Consent, I certdy that the waste minimization statement idenfified in 40 CFR 262.27(a) (itI am a large quantity generator) or (b) (i11 am a small quantity generator) is We. GemeaterslOfferors Printedrryped Name Signature Month Day Year J r 16. Inlemabonal Shipments ❑ImporttuU.S. ❑E.Ind from U.S. Port ofentrylexit z Transporter signature (for exports only): Date leaving U.S.: w 17. TranspoderAcknGwedgmenl ofRus:eipl of Materials Transporter l PrinledRyped Name Signabue Month Day Year O a CTransporter Pdntedffyped Name Signature IAonM Day Year r } 18. Discrepancy 18a. Discrepancy Indication Space ❑ Duonfity ❑Types ❑Residue ❑ Partial Rejectors ❑ FIA "Itcon Manifest Reference Number 18b. Alternate Facility (or Generalar) U.S. EPAID Number J U car- Fadlitys Phone: W 18c Signature ofAllemate, Facility (or Generamr) Month Day Year 6 z y19. Hazardous Waste Report Management Method Codes (i.e.. codes for hazardous waste lreabnent disposal, and recycling systems) 0 1. 2. 3. 4. 20. Designated Facility Offer oroperator Cerfificallon of receipt of hazardous materials covered by the manifest except as noted in Item las Printedffyped Name Slgnalure MoNh Day Year EPA Form 0700.22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY'S COPY