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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 MANIFEST - r 5.Generator's Name and Mailing Address ' ' �°`�r� �" %4 Generator's Site Address(if different than mailing address) f Generator's Phone: 6,Transporter 1 Company Name U.S.EPA ID Number 7,Transporter2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number ` Q Com. Facility's Phone: ga. gb.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers .Unit 11.Total 12 i and Packing Group(if any)) No. Type Quantity 12.lUnitoi, 13,Waste Codes w + I' Z 2' cs 3. 4. 14.Special Handling Instructions and Additional Information 15. GENERATOR'SlOFFEROR'S CERTIFICATION: f 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 fabeledlplacarded,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,1 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 am a small quantity generator)is true. Generators/Offeror's PrmtedlType_d Ni Signature 3 ' "'" ��/r ;...,,•� Month Day Year 16.International Shipments ~ ❑Import to U.S. ❑Export from U.S:' Port of entry/exit:L ? Transporter signature(for exports only); f' Date leaving Li 17,Transporter Acknowledgment of Receipt of Materials il Transporter 1 PrintedlTyped Name Signature Month Day Year �,LL A� � ��_-~ Q Transporter 2 Printed/Typed Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑ FuII Rejection 18b.Alternate Facility(or Generator) Manifest Reference Number: U.S.EPA ID Number V LL Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Q Month Day Year Z 19,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LLI 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 Printed/Typed Name�f Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete DESIGNATED FACILITYTO GENERATOR