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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved,OMB No.2050-0039 ,FJUNIFORM HAZARDOUS 1'.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4 Manifest Tracking Number WASTE MANIFESTS KS 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Generator's 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 Facility's Phone: k_—,. n ga.. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 1. x Z 12. J 6 3. 4. 14.Special Handling Instructions and Additional Information 15. r;ENERATOR'S/OFFEROFFS CERTIFICATION: thereby declare that tiie`confents'of this consignment are iuliy and accurately described above"bith$proper stripping 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)(if I am a small quantity generator)is true. FGeneratcrslOfferorsPrintedlfypedName Signature–_ „ Month Day Year _J 16.International Shipments ~ ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Z Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials OTransporter 1 Printedffyped Name Signature Month Day Year CL Z Transpo ei 2 Pdn ed/Typed Name Signature Y Month Day Year E- 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 <1 Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z 19.Hazardous Waste Report Management Method Codes(Le.,codes for hazardous waste treatment,disposal,and recycling systems) L 2. 3. 4. F 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Pnntedffyped Name Signature Month Day Year A EPA Form 8700 22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY T®GENERATOR