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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.O l3 No.2050-0039 UNIFORM HAZARDOUS. 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFI_$T J J K 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Ganerator'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 91.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./Vol. 1. 4Q ilF z 2. uu 0 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 labeled/placarded,and are in all respects in proper condition for transport according to applicable intemationai 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 EPAAcknowedgment 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. GeneratorslOfferor's PrintedlTyped Name Signature Month Day Year ,-i 16.lntemational Shipments t= ❑Import to U.S, ❑Export from U.S. Port of entrylexit: z Transporter signature(for exports only): Date leaving U.S.: 17.Transporter Acknowledgment of Receipt of Materials OTransporter 1 Pr nted ypad Name Signature Month Day Year n en .a Transporter Printecjyped Name Signature Month Day Year a H 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J V LL Facility's Phone: Lu 18c.Signature ofAltemate Facillty(or Generator) Month Day Year a z Fn 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 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 PrintedlTyped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GEN'ERATOR'S INITIAL COPY