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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 4 j G B F :r 5. Generator's Name and Mailing Address Generator's SlleAddress (if different than mailing address) Generator's Phone: 6. Transporter i Company Name U.S. EPA ID Number Ir 7. Transporter 2 Company Name U.S, EPA ID Number 8. Designated Facility Name and Site Address U.S. EPA ID Number Ir 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 Wt.Nol, 1 . O H t ; i UJ i = 1 3. 4. 14. Special Handling Instructions and Additional Information L LY ,. 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 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 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. GeneratoeslOfferors Printed/Typed Name Signature Month Day : .Year —r 16. International Shipments H ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: Z Transporter signature (for exports only): Date leaving U.S. : w 17. Transporter Acknowledgment of Receipt of Materials OTransporter 1 Printedrryped Name Signature Month Day Year a ZTransporter 2 Printed/Typed Name Signature Month Day Year f- 18. Discrepancy 18a. Discrepancy Indication Space ❑ QuantityType❑ YP ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: 18b, Alternate Facility (or Generator) U.S. EPA ID Number U LL Facility's Phone: Lo 18c. Signature of Alternate Facility (or Generator) onth Day Year Z f ff 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) LU 1 . 2. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printedrryped Name Signature nth Day Year n EPA Form 87022 (Rev. 3-05) Previous editions are obsolete. f' X � . } - _ f :T C4 � Ev➢ � E3ta`�'fva > c rr�or�a° rnr � nrnv '