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Please print,or type.(Form designed for use on elite 12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1 Ganorator ID`Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tacking Number WASTE MANIFEST J J 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Generator's Phone: 6.Transpmw i 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: aa. 9b.U.S.DOT Description(including ProperShipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unl# HM and Packing Group(if any)) No. Type Quantity wt./Vol 13.Waste Codes 1. LU 4 2 i c7 3. 1 14.Special Handling(Instructions and Additional Informatlon f-t Ovti .13 �;t 46CAl,rr';:;; & PROITt:.�VE t:'{-4l l'f{'Y,;�IC� 7.4Hq EMERGENCY CON W--'f; f�!'f�K WA;.. Dl- } { Ill 9b2) N471NC. r :.� 111111111111 hili 1011111ll 111111 HIM lilt',1111111 I'll,Il�1 f.�.EA(•t';¢'fUf�}t-f7 j t:rR,pf9�+Fi � 1 -,'i�Fi. �7�g.,,1 �tsrTFt - ,..•' ., 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€abeiedlplacarded,and are in all respects In proper condition for transport.according to applicable intemaVonal and national governmental regulations.If export shipment and I am the Pdmary Exporter,I certify that the contents of thts consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minim€zabon statement identified in 40 CFR 262.27(a)(if I am a farge quantity generator)or(b)(if I am a small quantity generator)is true. GeneralorslOfferor's PrintedlTyped Name Signature Month Day Year —r 16.International Shipments i= ❑Import tc U.S. ❑Expart from U.S. Paul of entrylexit: Transporter signature(for exports only): Date leaving U.S.: 17.Transporter Acknowledgment of Receipt of Materials ULA I— Transporter 1 PrintedlTyped Name Signature Month Day Year O 13 U) Q Transporter 2 PrintedlTyped Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity Type Residue Partial Rejection ❑Fu11 Rejection Manifest Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA ID Number 3 V� w Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year Q VS19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) C 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 PrintedfFyped Name Signature Mor#h Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete, GENERATOR'S INITIAL COPY