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Please print or type. (Form designed for use on elite (12-pitch) typewriter.) Form Approved. OMB No 2050 UNIFORM HAZARDOUS 1 . Generator ID Number 2. Page 1 of 3 Emergency Response Phone 4 Manifest Tracking Number 3 3 ; WASTE MANIFEST 5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) { iv n i r f Generator's 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 Fadlity's Phone , , : , ga, 9b. U.S. DOT Description (including 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 WtJVoI. s.. LU 2• I 30 4: i 14. Special Handling Instructions and Additional Information v3 , ; N ll< ! t . .TJ 15. GENERATOR'S/OFFEROR'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 labeled/placarded, 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 EPAAdmowiedgment of Consent certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) '(ff l am a small quantity generator) is true, GeneratoeslOfferoes Printed/ryped Name Signature , ,, Month Day Year. / •� 16. International Shipments l- ❑ Import to U.S. ❑ Export from U.S. ./ Port of entrylexit f'3 MUNNOWSTransporter signature (for exports only): Date leaving U.S.. L 17, TransporterAcknowiedgment of Receipt of Materials U Transporter 1 Printedfiyped Name Signature Month Day Year p ell aTransporter 2 Pdntedrryped Name Signature Month Day Year 18, Discrepancy 18a. Discrepancy Indication Space Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: 18b, Allemate Facility (or Generator) U.S. EPA ID Number J_ G3 Facilitys Phone: Month Da Year W tact Signature of Alternate Facility (or Generator) y a Z N19, Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) D 121 3. 4. �' � fr j 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 Signature Month Day Year EPA Form 8700.22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY'S COPY