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Please print or type. Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS1.Generator ED Numher 2.Page 1 pf 3 Emergency Response Phone 4 Manifest Trackrng Numher WASTE MANIFEST $ A, S.Generator's Name and Mailin Address Generator's Site Address(if different than mailing address) Generator's Phone: i 6.Transporter 1 Company Name 7 U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number B.Designated Facility Name and Site Address U.S.EPA ID Number ; - 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 Wt.Nol, w r 2. LU //ryry 3. i 7 I 4. 3 14.Special Handling Instructions and Additional Information 15. GEN ERATOR'SIOFFEROR'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 labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and nalion8l 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 21(if I am a large quantity generator)or(b)(if I am a small'quantity generator)is true. GeneraloeslOfferor's PrintedlTyped Name Signature Month Day Year 18.International Shipments ❑Import to U.S. ❑Export from U.S. Port of entrylexit: Transporter signature(for exports only): Date leaving U.S.: 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 PrintedlTyped Name Signature,. Month Day Year Transporter 2 Printed /Typed p !Typed Name Signature Month Day Year 18.Discrepancy 1 Be.Discrepancy Indication SpaceElQuandty ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number U i� Facility's Phone: L" 18c,Signature of Alternate Facility(or Generator) Month Day Year Z CD19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) ® 1. 2. 3. 4. 2g.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Prnted Typed Name Signature Month Day Year EPA Form 8700-22(Rev:12-17) Previous editions are obsolete. G.mNERAT R S X'71AL__CMP