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Please print or type.(Form designed for use on elite12- �v� I ( pitch)typewriter.) UNIFORM HAZARDOUS 1.Generator ID Number Form Approved.I No.2050-UG3 WASTE MANIFEST 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking NameNum .�ryz Number - 5.Generator's Nae and Mailing gddreSs 4� &: JJ K Generator's Site Address(if different than mailing address) Generators Phone, 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name t s 1j a U.S.EPA ID Number 8.Designated Facility Name and Site Address r` U.S.EPA ID Number Facility's Phone: 9a. 9b.U.S.DOT Description(inducing Proper Shipping Name,Hazard Class,ID Number, HM and Packing Group(if any)) 10.Containers 11.Total 12.Unit O 1 No. Type Quantity Wt./VOI. 13.Waste Codes F 1s i ILLI 2 3. I 4. 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 descnbed above by the proper shipping name,and are classified, z s: yJ al marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable intemational 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. Packaged, 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 true. Generator's/Offeror's Printed/Typed Name Signature --r 16.IntemafiMontt Day Year onal Shipments - =% - ~ ❑Import to U.S. _ Z Transporter signature(for exports only): ❑Export from U.S. laort Of entry/exit _ W 17.Transporter Acknowledgment of Receipt of Materials Daie leaving U.S.: —__--- j1X Transporter 1 PrintedlTyped,(alame O Sr�nat�rE n . oath Day Year Transporter 2 Pri 1-1 lyli Name es s F— Signature Month Da,^y Year 18.Discrepancy 18a.Discrepancy Indication Space s'F ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Fes— 18b Alternate Facility{or Generator) Manrfest Reference Number: t 0 U.S.Cl ID Number I Facility's Phone: w 18c.Signature of Alternate Fadlity(or Generator) Month Day Year 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) �4 L 2. 3. 4 fl 7 __ L20.Designated Facility Owner or Operator:Certification Of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/typed Narne Signature *#' Month Day Year EPA Form 8700.22(Rev.3-05) Previous editions are obsolete. DESIGNATE® =AOLITY TO GENERATCR