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Please print or type.(Farm designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emerggncy Resppnse Phone 4 ManlfeatTracking Number WASTE MANIFEST j S KS 5.Generator's Name and Mailing Address Generators Site Address allingacEmlis LZ Ovtu Generators Phone: J U N 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name 8.Designated Facility Name and Site Address U.S.EPA ID Number ._A 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 HM and Packing Group(if any)) No. Type Quantity WtNol. O r Q W 3. 4. j 14.Special Handling instructions and Additional Information 1 , r t rWjlt 1. i' ;"4t=�t�(t.r li j '.:�!{•�it~1 l fl y� l 1. F/ ',{ 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)(if l am a small quantity generator)is true. Ge neratoes/Offeroes PrintedRyped Name Signature P, r Month Dav Year —J 16.Intemational Shipments F— ❑Import to U.S. ❑Export from U.S. Port of entrylexit: 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 a Z Transporter 2 PrintediTyped Name ! Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity k ❑Type ❑ ❑Residue ❑Partial Rejection Full Rejection Manifest Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U rai Facility's Phone: LO 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z Fn19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 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 Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. G E. _. _ .. a it ,10 F Y