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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Farm Approved.OMB No.2050.0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST ; ( 1 ' r1 r' -j r; r G B F, 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 8.Designated Facility Name and Site Address U.S.EPA ID Number Facility's Phone: ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit .3.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. t O Z 2. W C7 — 3. 4 14.Special Handling Instructions and Additional Information 15. GEN ERATOR'SfOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shgpirg name,and are classified,packaged, marked and labeledlplatarded,and are in all respects in proper condlbon 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 EPAAcknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(A I am a large quanlily generator)or(b)(if I am a small quantity generator)is true. GeneratorslOfferors Printed[Typed Name Signature Month Day Year —J 16.International Shipments r Elo Import to U.S. ❑Export from U.S. on of entry/exit: z Transporter signature(for exports only): Date leaving U.S.: Or 17.Transporter Adroowledgmenl of Receipt of Materials WTransporter 1 Prnted7Typed Name Signature Month Day Year O a . Z Transporter 2 Printed/Typed Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Altemate Facility(or Generator) U.S.EPA ID Number U u- Facility's Phone: W18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 1. 2 3. Notice:State of California requires 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the marifestexcept as r gerneratOr t0 photocopy and mall t0 Printed/Typed Name Signature DTSC with 30 days: Day Year P.0 30)(X500 EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. Sacramento,Ca 95812-0400 GENERATOR'S INITIAL COPY