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Please print of type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No_2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Erne gency Response Phone 4.Manifest Tracking Number WASTE MANIFEST J J K 5.Generatoes Name and Mailing Address Generator's Site Address(if different than mailing address) GeneraiDes Phone: 6.Transporter t 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 Io Number Facility's Phone: %, 91.U.S.DOT Description(including Proper Shipping Name,Hazard Cl,.,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) 13.Waste Codes No. Type Quantity WtNol, 1. O w z. � � I 3. I ! 4. 14.Special Handling instructions and Additional Infomtafien 15. GENERATOR731OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fufly 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 national governmental regulations.If export shipment and I am the Primary Exporter,i certity that the contents of this consignment conform to the terms of the attached EPAAcknowledgment 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. GenaratoeslOfferoes PrintedlTyped Name Signature Month Day Year 16.International Shipments h— ❑Import to U.S. ❑Export from U.S. Port of entrylexit: Transporter on!exports for nature si ex 9 ( P Yk Data leaving U.S.: 17.Transporter Acknowledgment of Receipt of Materials LU GTransporter 1 Printed/Typed Name Signature Month Day Year a Q Transporter 2 PrintedrTyped Name Signature Month Day Year F 18.Discrepancy 18a.Discrepancy Indication Space Quantity ❑ pe Ty ElResidue ❑Partial Rejection ❑Full Rejection Manifest Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA ID Number U Facilitys Phone: W 18c.Signature ofAltemate Facility{or Generator) Month Day Year a Z H19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) G 1. 2. 3. 4. 20tDesignated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a pad Name Signature Month Day Year EPA f=orm 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY