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Please print or type.(ori m designed far u� se on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2,Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST G B C 5.Generators Namc 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 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 HM and Packing Group(if any)) 13 Waste Codes No. Type Quantity Wt.Nol. t. Cr Z 2. w C9 3 4, 14.Special Handling Instructions and Additional Information 15. GENERATOR'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 labelediplacarded,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 ofZ6nsent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or )0 1 am a small qu.._ �,' Generator arOfferor s PrintedlTyped Name Signature Month Day Year _t 16.International Shipments Z ❑Import to U.S. ❑Export from U.S.' Port of entry/exit: Transporter signature(for exports only�: Date leaving U.S.: E 17.TransperterAcknowledgment of Receipt of Materials Transporter bPtintedlrypedName O Signature Mon(ft Day Year CL , - e, Q Transporter 2.PrintedfTyped Names Signature b9onth Day' Year 18.Discrepancy 18a.Discrepancy Indication Space (`' Quantity Type ❑Resicue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number v Facility's Phone. 18c.Signature of Alternate Facility(or Generator) Month Day Year G S CO 19.Hazardous Waste Repo ivlanagemenl Method Codes p.e..codes for hazardous waste treatment,disposal,and recycling systems) LLJ 1 2. 1 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. TRANSPORTER'S COPY