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"-brcs,l�,z S`kw ^ 1 e Please print or tvoe. (Form desianed for use on elite (12 -aitch) tvoewdter l Fin„ A --,l r1AAR Aln Xnsnsnoo EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S hNi T 3w? COPY UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number WASTE MANIFEST JJ K 5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) Generator's Phone: 6. Transporter 1 Company Name U.S. EPA ID Number 7. Transporter 2 Company Name U.S. EPA ID Number B. Designated Facility Name and Site Address U.S. EPA ID Number Facility's Phone: 9a. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class. ID Number, 10. Containers 11. Total 12. Unit HM and Packing Group (if any)) Quantity Wt.A/ol. 13. Waste Codes No. Type 1. O Q Z 2. LU C7 3. 4. 14. Special Handling Instructions and Additional Information 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. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (f I am a small quantity generator) is true. Generators/Offerors Printed/Typed Name Signature Month Day Year J i- 16. International Shipments ❑ Import ❑ Port Z to U.S. Export from U.S. of entry/exit: Transporter signature (for exports only): Date leaving U.S.: CE 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 Primed/Typed Name Signature Month Day Year O a BTransporter 2 Printed/Typed Name Signature Month Day Year F- 18. Discrepancy 8a. Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue Partial Rejection ❑Full Rejection Manifest Reference Number: >- 181b. Alternate Facility (or Generator) U.S. EPA ID Number J U U Facility's Phone: LU 18c. Signature of Alternate Facility (or Generator) Month Day Year a Z V519. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) ul 0 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 v Printed/Typed Name Signature Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S hNi T 3w? COPY