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.r 142 Plaasa nrint or tvne_ (Form designed for use on elite (12-Ditcni tvoewriter.) Form Approved, OMB No. 2050-0039 EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number WASTE MANIFEST KS 5. Generators Name and Mailing Address Generators Site Address (if different than mailing address) fiNN€Fy Generators 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 VT". Facility's Phone: ga 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes No. Type HM and Packing Group (if any)) Quantity Wt Nol. 1. W Z 2. W 3. 4, 14. Special Handling Instructions and Additional Information tl3# t f° 1 k ' R• i1i i 1 '�--' i Y �. ,..., t f { . r 1.'r. 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) ('rf I am a small quantity generator) is true. Generators/Offerors Printed/Typed Name 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 Transporter 1 Printed(Typed Name Signature Month Day Year O CL Z Q Transporter 2 Printe,Oyped Name Signature Month Day Year 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity El Type ❑Residue ❑Partial Rejection El Full Rejection Manifest Reference Number: 181b. Alternate Facility (or Generator) U.S. EPA ID Number J U LL Facility's Phone: w 18c. Signature of Alternate Facility (or Generator) Month Day Year Q1Z N 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste -treatment, disposal, and recycling systems) 0 1. 2. 3. 4. T 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a -i Prinbd/Typed Name Signature Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY