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Id.' Form designed for use'ci,-elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0639 ARM HAZARDOUS 1,Generator ID Number 2.Page 1 of 3.Emgrgency Response Phone 4,Manifest Tracking Number IWTEaMANiFEST ;'.I ,,' JJK 5-Generator's Name and Mailing Address Generator's Site Address(If differant than mailing address) Generators 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 I 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 WtNoi. 1.'.! EL € 4. 14.Special Handling Instructions and Additional Information 15. GENERATOR'SlOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classifed,packaged, marked and labeledlplacarded,and are in all respects in proper wriditlon 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 a#tached EPA Acknowledgment of Consent, I certify that the waste minimization statement identified 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'slOfferor's PrintedlTyped Name Signature Month Day Year .A 161.International Shipments F- ❑Import to..U.S. ❑Export from U.S. Port of entrylexit: Transporter signature(for exports only): Date leaving U.S.; LU 17.Transporter Acknowledgment of Receipt of Materials Transporter 1-PrintedlTyped Name ___.._..- Signature r Month Day Year Z Transporter 2 Printed/Typed Name- " Signature Month Day Year F 18.Discrepancy II��II 18a.Discrepancy Indication Space ❑ Quantity 1-1Type El Residue LI Partial Rejection ❑Full Rejection Manifest Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA ID Number 'v Facility's Phone: Lu 18c.Signature of Alternate Facility(or Generator) Month Day Year Z 2 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) ® 1. 2, 3. 4. 20,Designated Facility Cwner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrintedfTyped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S ]INITI]AL COPY