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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.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST01473318f- JJr% 5.Generator's Name and Mailing Address Generator's Site Address(if different 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 B.Designated Facility Name and Site Address U.S.EPA ID Number 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.Nol. 1 ! s g W 2. R E G F.I V b-' 3. FE B-1-71.016—J--l- 4. . 1.01 w..—..,4. mr- 14.Special Handling Instructions and Additional Information 15. GENERATOR'S/OFFEROR'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 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 aln a small quantity generator)is true. Generator'slOfferor's Printed/Typed Name Signature 1 Month Day Year P e V ♦v'f+ f n- J 16.lntlamafl6nal Shipments - z Import to U.S. ❑Export from U.S. '. ,°Port of entry/exit: Transporter signature(for exports only): Date leaving U.S.: IX 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 PrintedlTyped Na*—' Sigiitituiv -4— Month Day Year O CL 44":Par's _ Q[MF�Redrrypiacl Name w Signature" Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type y Residue ❑Partial Rejection El Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J V I Facility's Phone: w 1 Bc.Signature of Alternate Facility(or Generator) Month Day Year a z N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) ® 1. 2. ]37- 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a [!!ne Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. 2EHER1Y 0n'G INITIAL COPY