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Please print or type. 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 4 JJK ` a 5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) Generator's Phonef', r + rr 6. Transporter 1 Company Name U.S. EPA ID Number 7. Transporter 2 Company Name U.S. EPA ID Number _ w B. Designated Facility Name and Site Addreo/ q, i = St.. €'* ` ' ?< :L# i o '_ U.S. EPA ID Number Y. T5� 99 Facility's Phone: 9a, 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 Wt.Noi. 1 . �jj l l �E�A V4F4, s�- f�O-A13°-OF' I FttA Aa L) P�Ox, I F R,l# r Y. t` fta:r v � O z 2. W O 3. 4. 14. Special Handling Instructions and Additional Information jT .'• t.a3 i.>.z f'x. . I f .l_ . . ,v Y t OFF F.1 � 5e 't:0:.. 15. GENERATOR'S/OFFEROWS 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 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 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. Generatots/Offeroes Printed/Typed Name ' Signature Month Day Year IFr � 16. International Shipments N ❑ import to U.S. ❑ Export from U.S. Port of entry/exit: Z Transporter signature (for exports only): Date leaving U.S.: Ce 17. Transporter Acknowledgment of Receipt of Materials Uj Transporter 1 Printed/Typed Name Signature Month Day Year a Transporter 2'P(intedfTypedName Signature Month Days Year 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 V w Facility's Phone: W 18c. Signature of Alternate Facility (or Generator) Month Day Year ~Q 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) UJ 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 Printed/Typed Name Signature Month Day Year EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. GENERATOR' S INITIAL COPY