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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 4 WASTE MANIFEST ?- 5.Generators Name and,Mailing Address ru"l-".. J J-a Generators Site Address(if different than mailing address) Generator's Phone: 6.Transporter I 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 Facility's Phone: 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,10 Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) No. Type Quantity Wt,Nol. 13.Waste Codes 0 3. ....................... 4. 14.Special Handling Instructions and Additional Information �CJ 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 EPAAcknowledgment 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. GeneratorstOfferor's Printed/Typed Name Signature Month Day Year 16.International Shipments El import to U.S. 0 Export from U.S. Pod of entry/exit: Transporter signature(for exports only): Dale leaving U.S.: UJ 17.Transporter Acknowledgment of Receipt of Materials 0 Transporter 1 Printed/Typed Name Signature Month Day Year Z Transporter 2 Printed[Typed Name Signature Month Day Year 18.Discrepancy 18a-Discrepancy Indication Space ❑ Quantity El Type El Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number., 18b.Alternate Facility(or Generator) U.S.EPA ID Number :3 LL Facility's Phone: LLJ 18c.Signature of Alternate Facility(or Generator) Month Day Year !R I Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) UJ 2. 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--' M.1hi Day Year EPA Form 8700-22(Rev.3-05) Previous ediflons are obsolete. PlES'ANATED FACILITY'S COPY