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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number UNIFORM HAZARDOUS JJ K WASTE MANIFEST 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Generator's Phone: U.S.EPA ID Number 6.Transporter 1 Company Name U.S.-EPA ID umber 7.Transporter 2 Company Name �,i k_ll ,;j U.S.EPA ID Number 8.Designated Facility Name and Site Address Facility's Phone: 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes ga. Quantity Wt.Nol. HM and Packing Group(if any)) No. Type ; Q 2J� r� z 2. 3.4. j i I i 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 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 intemafional and national governmental regulations.If export shipment and I am the Primary Exporter,1 certify that the contents of this consignment conform to the terns of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if1 am a small quantity generator)is true. GeneratorslOfferor's Printed/Typed Name Signature Month Day Year 116.International Shipments ❑Import to U.S. ❑Export from U.S. Port of entrylexit: F— Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Ice Transporter 1 Printed/Typed Name Signature Month Day Year O a Month Day Year QTransporter 2 Printed/Typed Name Signature H 18.Discrepancy 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: U.S.EPA ID Number 181h.Alternate Facility(or Generator) J_ V LL Facility's Phone: Month Day Year W 18c.Signature of Alternate Facility(or Generator) Q Z C2 1-9 Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) G 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 Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGi\lA a ED 1=ACILIT;TO U