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Please print or type.(Form designed for use On elite(12-pitch)typewriter.) Form Approved.OMR No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 10l 3.Emergency Response Phone 4.Manifest Tracking Number JJ WASTE MANIFEST 6.Generator's Name.and Mailing Address Genenlofs Site Address(if different than mailing address) Generator's Phone'. 6,Transporter 1 Company Namy. U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8;4es4nated Faatiy,Name and Sile Address U.S.EPA 10 Number Fader Is Phone: as. 9b.U.S.DOT Descripfim(including Proper Shipping Name,Hazard Clens,ID Number. 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group Of any)) No. Type Ouaniy WtNd. K Oa K 2 2. w 4, 1 14.Special Handling Instructions and Additional Information - �i 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately desoibed above by the proper shipping name,and are classified,packaged, marked and labeledrplacarded,and are in al respects N 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 EPAAcknowledgment of Consent. I certify that the walla midmization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(ifI am a small quantity generator)Is true. Genenlor'sMeror's Prinled7Typed Name Signature Month: Daly, Year J 16.International ShipmentsF ❑Impact to U.S. E.Pon from U.S. Port of engylexil: 2 Transporter signature(for exports only): Date leaving U.S: 17.Transporter Acknowledgment of Receipt of Maters LAU K Transpoder 1 PdnWTyped Name Signature will Day Year O 13.ZMonti Day Year Transporter 2 PrcneMyped Name Signature I 18.Discrepancy 183.Discrepancy Indra6m Space El Quantity [:)Type EIResidue ❑Partial Rejection ❑Full Retectim Manifest Reference Number 18b.Alternate Facy(or Generator) U.S.EPA ID Number '4ti J V LL Fecal Phone: Month Day Year us 18c.Signature o(AAernate Facility for Generator) 6 Z N19.Hazardous Wasle Report Management Method Codes(i.s.,codes for hazardous waste treatment,disposal,and recycling systems) O 1' 2. 3. 4. 20.Designated Fadi y Caster or Operator:Certification of receipt of hazardous materials covered by the manifest except as ntled in Item Ise Month Day Year 1 PnntedRyped Name Signature EPAForm 8700-22(Rev.34),S) Previous editions are obsolete. GENERATOR'S INITIAL COPY