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Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) Form Approved. OMB No. 2050-0039 EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY UNIFORM HAZARDOUS 1, Generator ID Number 2. Page 1 of 3. Emergency Response Phone 14, Manifest Tracking Number ': WASTE MANIFEST 4.) LI ') I18-63 G B F 5. Generator's Name and Mailing Address Generator's Site Address (0 different than mailing address) Generator's Phone: 6. Transporter 1 Company Name U.S. EPA ID Number 7. Transporter 2 Company Name U.S. EPA IO Number 8. Designated Facility Name and Site Address U.S. EPA ID Number Facllity's Phone, ga 9b. US DOT Desoiptlon Including Proper Stepping Name, Hazard Class. ID Number. 10. Containers 11, Total 12. Unit 73. Waste Codes N. Type HM and Packing Group (if any)) Ouanfity WINol. 1. 0 vF w 2 3 4. 14. Special Handling Instructions and Additional Information 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and she classified, packaged, marked and IabNediVatarded. and are in all respects In proper condition for transport according to applicable mtemationaland national governmental regulations. If export shipment and I am the Primary Exporter, I certify that the contents of this consignment conform M the lemo of the attached EPAAcknowedgment of Consent I tartly that the waste miNmization statement identified in 40 CFR 26227(a) (d I am a Urge quantity generator) or (b) III I am a small quantity generetor) is frms, Genereto's(OBemes Pdnted7Typed Nam Signature Month Day Year J mational Shipments ❑ Import to US. ❑ Expol from us. Port Nentry/exit 2F Transpprter signatum (for exports only): Date leaving U.S.: w 17. TmnsporterA&jw ledgmem of ReoW of Materials Transporter 1 PdnledlTyped Name Signature Month Day Year a M; -y . h . G Transporter 2 Prirsedrryped Name Signature--' Month Day Year R' ti Discrepancy i18. 18s. Discrepancy Indication Space ElOuantiry ❑ Type 1:1Residue 1:1Partial Rejection ❑ full Rejection Manifest Reference Number. 18lb Alternate Facility (or Generator) U.S. EPA ID Number J U LL Facllitys Phone: w 18c. Signature ol'Altemate Facility (or Generales) Month Day Year Q Z N19. Heurdous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment. disposal. and recycling systems) 7. 2. 3, 4, 20, Designated Facility Omer or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a 1 Printedfryped Name Signature Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY