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C-A, 1/g/) -- Please print or type.(Form designed for use on elite(12-pitch)typewriter.) UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest TrackinrNyOved.OMB No.2050-0039 WASTE MANIFEST 5.Generator's Name and Mailing Address JJ�( I� Generators SiteAddress(if different than mailing address) Generator's Phone: 6.Transporter 1 Company Name ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility-111--d Site Address - - - U.S.EPA ID Number Facility's Phone: 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number. HM and Packing Group(if any)) 10.Containers 11.Total 12.Unit 1. No. 13.Waste Codes � Type Quantity Wt./Vol. O Z W 2. 0 3. 4. 14.Special Handling Instructions and Additional Information r 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labeled/placarded,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 this 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)(III am a small quantity Generator's/Offeror's PrintedlTyped Name q ty generator)is true. -.-• Signature Month Day Year 16.International Shipments Z ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Transporter signature(for exports only): w 17.Transporter Acknowledgment of Receipt of Materials Date leaving U.S.: -- Transporter 1 Pnnted/Typed Name a Signature Month Day Year (n ZZ Transporter 2 PrintediTyped Name Ix Signature F- Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection 1.- 180.Alternate Facility(or Generator) Manifest Reference Nwnbec U U.S.EPA ID Number LL Facility's Phone: w 18c.Signature orAlternate Facility(or Generator) z Month Day Year as19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) W 1 a F 3. 4. 20.Designated Facility Owner or Operator:Cert ficabon of receipt o7 f hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-OS) Previous edition's are obsolete. D�'SIG,`+i 4TED FACILITY TO GENERATOR