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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 Generator's Site Address(if different than mailing address} Generators Phone: 6.Transporter 1 Company Name US.EPA ID Number 7.Transporter 2 Company Name U.S.EPA tO Number 8.Designaled 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 HM and Packing Group(If any)) 13.Waste Codes No. Type Quantity Wl.Nol. 1. O w z z. w Ch 3. 4. 14.Special Handling instructions and Additional Information 15. GENERATOR'SIQFFERQR'S CERTIFICATION: I hereby declare that the contents of[his 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 applioab:e international and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of[his consignment conform to the terms of the attached EPAAcknowledgmenl 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. Generatorsi0iferors Printed/Typed Name Signature Month Day Year r i6.International Shipments Z ❑Impod to U.S. ❑Export from U.S. Pori of entryfexit: Transporter signature(for exports onil Dale leaving U.S.: LW 17.Transporter Acknowledgment of Receipt of Materials OTransporter 1 PrintedlTyped Name Signature Month Day Year cri a it ti4Y f__ y.yy Q Transporter 2 Printed/Typed Name Signature Month Day Year F 18.Discrepancy 1 Be.Discrepancy indication Space El Quantity ❑Typo ❑Residue ❑Partial Ftejecfon ❑Full Rejection Manifest Reference Number: 18b.Alternate Facifily(or Generator) U.S.EPA ID Number U Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) © 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 [Parted/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACII_ITYTO GENERATOR