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Please print or type. (Form designed for use on elite (12-1 typewriter.) Form Approved. OMB No. 2050-0039 [ UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Resp n Phone 4 Manifest Tracking Number �e _ ( /,� 11 WASTE MANIFEST $j 8mF , L,.£ m.A IJJ 6C S. Generators Name and Mailing Address Generators SiteAddress (if different than ailing address) Generators Phone: _ f 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 .t 1 U.S. EPA ID Number isI Li — Facifys 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 Wt./Vol. a 1 . z 2. Ulu CO 3. 4, e 14. Special Handling Instructions and Additional Information 15. GENERATOWSIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, ard 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 l am the Primary Exporter, I caddy that the contents of this consignment conform to the terms of Ne attached EPA Acknowledgment of Consent. I certiy that the waste minimizalion statement identified in 40 CFR 262.27(a) If l am a large quantity generator) or (b) (if I am a small quantity generator) is (me. Generators/Offerors Printed/Typed Name Signature - Month Day Year If If 16. International Shipments r ❑ Import to U.S. ❑ Expel from U.S. Pod of entrylexil: = Transporter signature (for experts only): Date leaving U.S.: w 17. TmnspoderAcknowledgment of Receipt of Materials Transporter i Printed/Typed Name Signature Month Day Year O a QlTyped Transporter 2 PnntedName Signature Month Day Year K 18, Discrepancy ', 18a. Discrepancy Indication Space ❑ Quantity ❑Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: 181b. Alternate Facility (or Generator) U.S. EPA ID Number J LLFacility's Phone: W Its. Signature ofAltemate Facility (or Generator) Month Day Year C z I 19. Hazardous Waste Repel Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 2. 3. 4. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item l8a PnntedifTyped Name Signature Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY