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0 10 - Form Approved. OMB No, 2050-0039 EPA Form 8700-22 (Rev. 3-05) Previous editors are obsolete. utiNIFkACYOR z5 iNi i tAL Gur 1 UNIFORM HAZARDOUS ' Generator I 2. Page 1 of 3. Emergency Response Phone 4. Manifest Trackinq Number I fo JJ K WASTE MANIFEST 5 Generator's Name and M3iltng Address Generator's Site Address (if different than mailing address) &'ncratc'es Phone 6 Traisponer 1 Company Name U.S EPA ID Number 7. Transporter 2 Company Name US EPA ID Number 87ps4gnalerl Facility Name and Site Address U.S EPA ID Number FaciLty's Phone: 9a 9b. U.S DOT Descriphon (including Proper Sh.,pping Name, Hazard Claes, ID Number, 10, Containers 11. Total 12, Unit 13. Waste Codes Type Hp,! and Pn;ng Group (if any))No, Quantity Wt NII, 0 Z Uj 4 14. Spejai Handling Instructions and Additional Information 15, GENERATORVOFFEROR'S CERTIFICATION: I hereby dectare that the contents of this consigrimamt are fully a d accurately described above by the proper shipping name, and are classified. packaged, marked and laholod1placarded, 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 EPAAcknowledgment of Consent 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 in* Printed.7ypeol Name Signature month Year -j International Shipments 0 Import to U.S.D Export from U.S. Port Of ertryrexit 116, Transpctlersignalure (for exports Only; Date leaving.0 S. IX I T Transporter Acknowledgment of Receipt of Materials W Transporter I Pnntpd,7yped Name Signature Month Da, year 0 Transporter 2 PantedTypedName Signature Month Day Year Ehsy:*epar:oy I1S. 1 Ba. D;screparxy Indlcat,,on Space El Quantity ❑ Type El Residue ❑ Partial Rejection Full Rejection Manifest Reference Number: I Bb. Aftemle Facility (or Generator) U.S. EPA ID Number U- Facihh' s Phone: Im W 1 8c Sigrature of Alternate Faciiity (or General Month Day Year Z 19 Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment. disposal, and recycling systems) iz LIJ 1 2 4. 20 Designated Faditty Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrintediTyped Name Signature Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editors are obsolete. utiNIFkACYOR z5 iNi i tAL Gur 1