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w Form Approved,OMB No.2050.0039 Please print or type.(Form designed for use on elite(12-pitch)typewriter.) 2.Pae 1 of 3.Emergency Response Phone 4.Manifest Tracking Number 1.Generator ID Number 9 r r 1 r'�r- JJ K UNIFORM HAZARDOUS - �.) i {j 11'_j ;, ;;) C, t;= WASTE MANIFEST 5.GeneratorS Name and Mailing Address Generetors Site Address(8 digerenl than mailing address) Generators Phone: U.S.EPAID Number 6.Transport 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and SileAddress Facild aPhan e: 9b.U.S.DOT Description('Including Proper Shipping Name,Hazard Class,ID Number, 16.Codainera tt.Toa) 12.Unit 9a. 13.Wawa Codes No. Type Quantity wt./Vol.and Packing Grout til any)) O Q K L 2. W 0 I 4. i 14.SPeCial Hardlmg ins----o s andAdpiUonel hrFomui9orr , . 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare Nat the contents of Nis consgnment are linty and aauralely descnbeit above by the proper shipping name,and are classified,packaged, marked and labeledrplacarded,and are in all respects In proper condition for transport according W applicable International and national governmental regulations.It export shipment and am the Primary Exporter,I comfy that the conanls of this consignment conform to the area of Ne attached EPA Acknowledgment of Consent. I bandy,that the waste minimization statement identified in 40 CFR 262 27ta)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Monty Day Year Generatordmc slO6emes PdRyped Name SignaWre 16.International Shipeenb ❑Imponto U.S. ❑Export from U.S. Pon of entry/exit: TDate leaving U.S.: — Transporter signature(for exports only): W 17.Transpork AcWwMedgmenlof Receipt of Materials Monty DaY Year ture Transporter 1 Prin edrFYped Name O n Monty Day I Year Transporter 2 Prinled/TYPad Name Sig law K r— ♦ 18.Discrepancy 188.Discrepancy Location Space ❑Type ❑Residue ❑Partial Ratection Full Rejection ❑ WanOty Manliest Reference Number U.S.EPA IO Number 186,Alternate Facikty(or Generator) Z3 V u4- Facility's Phone: Month Day Year W 18c.Si9natureafAsemate Faclity(or Generator) Q 2 y19.Hazardous Waste Report Management Melhad Codes O.e.,codes for hazardous waste treatment,disposal,and recycling systems) 4 uz 1 2. 3. h2D. gnated Fediry Oaner ter Operator.Cerohalion of receipt of hazardous materials covered by the manifest except as noted in Item Ida Month Day Year yped Name Signature EPA Form 8700.22 GENERATOR'S INITIAL COPY (Rev.3.05) Previous editions are obsolete.