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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOU5 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number �[(' WASTE MANIFEST (V KS 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) Generators Phone: E.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA 10 Number 8.Designated Facility Name and Site Address U.S.EPA ID Number Facility's Phone: 9a 91b.U.S.DOT Description(induding 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.lVol. 1. aO G: z 2. C7 3. 4. 14.Special Handling Instructions and Additional Information 15. GENERATOR'SlOFFEROR'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 labeledlplacarded,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)(ifl am a small quantity generator}is true. Generato'slORerofs Printed/Typed Name Signature Month Day Year J 116.Intemafional Shipments T... ❑Impart to U.S. Export from U.S. Port of entrylexit: Transporter signature{far exports only): Date leaving U.S.: LX 17.Transporter Acknowledgment of Receipt of Materials t2 Transporter 1 PrintedfTypW Name Signature Month Day Year CO Transporter PrintedfTyped Name Signature Month Day Year a 18.Discrepancy 18a,Discrepancy indication Space ❑ Quantity ❑Type ❑Full Re ❑Residue ❑Partial Rejection {.tion Manifest Reference Number: 18b.Alternate Fnlity(or Generators U.S.EPA ID Number .a U ra Facility's Phone: � 18c.Signature of Alternate Fadlily(or Generator) Month Day Year a Z 55 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LU 1. 2. 3. 4. 20,Designated Facility Owner or Operator:Certification of receipt of hazardous malerials covered by the manifest except as noted in Item i 8a Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR