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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. JJ 5.Generators Name.and Mailing Address Generator's Site Address(if different than mailing address) Generator's Phonex, 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter Company Name. U.S.EPA tD Number 8.Designated Facility Name and Site Address U.S.EPA ID Number Facility's Phone: :t 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. --- t I i I � 4. 14.Special Handling Instructions and Additional Information ) 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 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. GeneratoeslOfferor's PrintedlTyped Name Signaturd Month Day Year ., —r 16.Intemationaushipments ►— ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Transporter signature(for exports only): Date leaving U.S.: 17.TransporterAcknowledgment of Receipt of Materials LIJ oTransporter 1 Prinledfryped Name Signature Month Day Year CL Q Transporter 2 Printed/Typed Name Signature Month Day Year or r- 18.Discrepancy 18a.Discrepancy Indication Space El Quantity ❑Type Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U LL Facility's Phone: W 18c.Signature ofAltemate Facility(or Generator) Month Day Year Q Z ti19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) p 1• 2. 3, 4 FDesignated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Name Signature Month Day Year r EPA Form 8700-22(Rev;3-05) Previous editions are obsolete.