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Please print or type.(Form designed for use on ite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator IDN tuber 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST1"1b'� 7 " JJ K 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,fSite Address U.S.EPA ID Number t, Facility's Phone: 9a, 9b.U.S.DOT Description(including Proper hipping 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, Z 2. W c� 3. 4. 14.Special Handling Instructions and Additional Infon iation 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 res cts 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 consigment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement id ntified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generator's/Offeror's Printed/Typed Name Signature y Month Day Year. .-j 16.International Shipments 1— ❑Import to U ❑Fjport from U.S. Port of entry/exit: z Transporter signature(for exports only): Date leaving U.S.: LOC 17.Transporter Acknowledgment of Receipt of Material Transporter 1 Printed/Typed Name Signature Month Day Year O �,.. N v aTransporter 2 Printed/Typed Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Typej j ❑Residue El Partial Rejection Full Rejection Manifest Reference Number: i8b.Alternate Facility(or Generator) U.S.EPA ID Number J U Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year z us19.Hazardous Waste Report Management Method Cod s(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) W 1. 2. 3. Notice: New federal forst. State of California requires generator to photocopy FrintedsflTyped nated Facility Owner or Operator:Certification f receipt of hazardous materials covered by the manifest except as noted in Item 18a and Irian to DISC within 30 dar-s: Name Signature P.O. Box 400. Sacramento. CA 91812-0400 EPA Form 8700-22(Rev.3-05) Previous editions are bsolete. GENERATOR'S INITIAL COPY