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Form Approved. OMB No. 2050-0039 EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. TRANSPORTER'S COPY UNIFORM HAZARDOUS 1. Generator ID Number 2. Page t of 3. Emergency Response Phone 4. Manliest Tracking Number � i �S 0 WASTE MANIFEST x ' 5. Generators Name and Mailing Address Generator's Site Address (if different than mailing address) Generators Phone: , r• 6. Transporter 1 Company Name U.S. EPA ID Number 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address U.S. EPA ID Number r'. Facility's Phone: ga 9b. U.S. DOT Description (including Proper Shipping Name, HIkard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes No. Type HM and Packing Group (if any)) i Quantity Wt.Nol. 0 1. -- Z 2. W 3. 4. 14. Special Handling Instructions and Additional Information 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declai a that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, marked and labeledlplacarded, 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 Conseltt. I certify that the waste minimization statement identified in 40 CF R 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. Generalor'slOfferor's Printed/Typed Name Signature Month Day Year 1- 16. International Shipments ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: - - - Transporter signature (for exports only): Date leaving U.S.: W 17. Transporter Acknowledgment of Receipt of Materials tE Transporter 1 Printed/Typed Name Signature , l Month Day Year CL Z Month Day Year Transporter 2 Printedfryped Name Signature H 18, Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ' ❑ Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number _J V rai Facility's Phone: w 18c. Signature ofAltemate Facility (or Generator) Month Day Year ZZ N19. Hazardous Waste Report Management Method Codes (i.e., code for hazardous waste treatment, disposal, and recycling systems) G 1. '� 2. 3. 4. r I -- 20. Designated Facility Owner or Operator: Certification of receipt of t azardous materials covered by the manifest except as noted in Item 18a PrintedlTyped Name Signature Month t Ye EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. TRANSPORTER'S COPY