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Please print or Woe. (Form designed for use on elite (12-pitchl Noemiriter.) - Form Aooroved. OMB No. 2050-0039 FPA Folin 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR I UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Number WASTE MANIFEST ,..,•,li... lTracking OO r��'i _1.."rJ DAT 5. Generator's Name and Mailing Address Generator's Site Address (If different than mailing address) Generator's Phone: S. Transporter 1 Company Name U.S. EPA ID Number I f 7. Transporter 2 Company Name U.S. EPA ID Number S. Designated Facility Name and Site Address U.S. EPA ID Number Facili Is Phone'. ga, 91c. U.S. COT Description (including Prefer Shipping Name, Hazard Class, ID Number, 10. Containers 11.70tal 12. Unit HM and Packing Group (If any)) OuanBty WWoI. 13, Waste Codes No. Type 1. � J- ad Z 2. w C7 3 4. 14. Special Handling Instructions and Addillonal Information 15, GENERATOR'SIOFFEROR'SCERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described shove bythe 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 regulators. Ii export shlpment and I am the Primary Exporter, I certly that the contents of this consignment conform to the tens of the attached EPAAcknowledgment of Consent. I certify that the waste minimization statement Identified In 40 CFR 26227(a) (d I am a large quantity generator) or (b) (If I am a small quantity generator) Is true. Generator'slOffemes PdnledlTyped Name Signature Month Day Year / F 16. International Shipments '-' ❑Import to U.S. ❑Export from U.S. P6dofentrylexit: z Transporter signature(for exports only): Date leaving U.S.: W 17Tr.\nsportarAcknowledgment of Recalls! of Materials - - Trdnspoiter 1 PrinledRyped Name Si atuie. ! C Mo N Day Yew ( Vr] . Transporter PrintedRyped Name Signature r Month Day r K I-- 18. Discrepancy Ise, Discrepancy Indication Space. ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number, 18b. Alternate Facility (or Generator) - ij (,, _ r,. .� f r U.S. EPA ID Number Zi V I I iI uQ. Facility's Phone: 1& Signature of Alternate Facility(or Generator) Month Day Year a 2 !, H19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 01. 2 3. 4. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted In Item 18a I20. 01Pad/Typed Name Stgnature Month Day Year FPA Folin 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR I