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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 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number �/ WASTE MANIFEST SKS 5.Generators Name and Mailing Address Generators Site Address lit different than mating address) Generators 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 Facllifys Phone: ea. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Gass,ID Number, 18.Contrera 11,Total 12,Unit HM and Pao"Group(d anyp No. Type Quantity WtNd. 13.Waste Cedes 1. C QO K z z. w (7 3. 4. 14.Special Handling Instructions ail Additional Information 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accumlely described above by the proper shipping name,and are detailed,packaged, marked and Iabeledlplacarded,and are in all respects in proper condition for transport according to applicable Intemationalard 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 EPAAcknoviledgmentof Concerns. I peroly destine waste minimizationstatenti l identified m 40 CFR 262.27(a)(It I man large quantlty generate)or(b)(Vim a small quentltygenemtm)is We. GenerzlMst00era's PdnledlTyped Name Sigrreture Moth Day Year —11 16.International Shipments El import to U.S. ❑Export from U.S. Pat afentry/ex8: t Transporter tignature(for expads onty): Date leaving U.S.: w 17.TransponerAcknovdedgmenl of Receipt of Materials Transporter 1 PdntsdlTyped Name Signature Monro Day Year O IL W R Transporter PrintedRyped Name SigaWre Month Day Year h I 10.Discrepancy 18a.Discrepancy indication Space ❑ Quantity El ❑Residue ElParow Rejection ❑Ful RejecSon Manifest Referaroa Number. 10b.Alternate Facility(a Generator) U.S.EPA ID Number J U LL Faciilys Phare: w 18c.Signature of Alternate Facility(or Genenuor) Month Day Year a z h19.Hazardous Waste Report Management Method Codes If.a.,codes for hazardous innate treatment,disposal,and recycling systems) 1. 2. 3. -T- 20.Designated Facility Ownernr Operator.Cerfificalion of receipt of hazardous materials overed by the manihsl azcept as rated in Item 18a Print typed Name Signature Monro Day ear EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR