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Please Drint or Noe. (Form desioned for use on elite (12-Ditchl tvoewriter.) Form ADDroved. OMB No. 2050-0039 EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. UNIFORM HAZARDOUS 1. Generator 10 Number 2 Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number WASTE MANIFEST SKS 5. Generators Name and Mailing Address Generators Site Address (f different than mailing address) Generator's Phone: 6. Transporter 1 Company Name U.S. EPA 10 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: ga 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes No. Type HM and Packing Group (if any);- Quantity WINoI. 1. cc O !- Q cc Z 2. w c� 3. 4. 14. Special Handling Instructions and Additional Information 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the con'ents 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 to applicable international and national governmental regulations. If export shipment and I am the Primary Exporter, I certify that the contents of Ibis consignment conform to the terms of the attached EPA Acknowledgment of Consent. 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. Generators/OfferoesPrintedffyped Name Sgnalure Month Day Year j F- 16. Internabonal Shipments ❑ Import to U.S. ❑Export from U.S. Port of entrylexit: z Transporter signature (for exports only): Date leaving U.S.: LE 17. Transporter Acknowledgment of Receipt of Materials IX Transporter 1 Printedffyped Name Signature Month Day Year O a rn Q Transporter 2 Prinled/Typed Name Signature Month Day Year H 18. Discrepancy 18a. Discrepancy Indication Space El Quantity ❑ Type ❑Residue Partial Rejection 0 Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number U rai Facility's Phone: w 18c. Signature of Alternate Facility (cr Generator) Month Day Year Q z 12 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 Printedrfyped Name Signature Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete.