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Please print or type.(Form designed for use on elite(12-pitch)typewrites) Form Approved.OMB No.2050-0039 v UNIFORM HAZARDOUS 1 Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.=address) ing Number WASTE MANIFEST 4JJ5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing '[:• .,;1 5.�;,.. .r,.. Generator's Phone: 6.Transporter 1 Company Name U.S.EPA ID Number r�•,Ai.�t F!:. �..ti ."r.,s 3 f§�:P'fi.^ ._E'."...��...: t[ '..:. %,.-'s,,t � •,�:-.-, 7.Transporter Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number Bl:; C?f,;;:z;i13, 3" .__. - Facility's Phone.--'. ` ga 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)) No. Type Quantity Wtivol. 13.Waste Codes 1 Y rZ c9 I 1 3. _ i 4. I f 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 are dassified,packaged, marked and labeledplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations,If export shipment and t 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. Generat5s/0(<er66?s Pnntedlryped Name Signature ;x Month Day Year (f —r16.International Shipments 1= ❑Import to U.S. ❑Export from US. Port of entry/exit: z Transporter signature(for exports only): Date leaving U.S.: w 17.TransporterAcimowledgment of Receipt of Materials OTransporter 1 Printed/Type0ame i Signature Month Dey Year Z Trnature Transporter 2 Printedlryped Name. Signature 9 Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial ReJectlon ❑Full Rejection Manifest Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA ID Number _J V Faculty's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year Z W19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 1, 2, 7 4, 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 Month Day Year EPA Form 8700-22(Rev.3-05)`Previous editions are obsolete, DESIGNATED FACILITY'S COPY