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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 1 Generator ID Number 2,Page 1 of 3.Emergency Response Phone 4,Manifest Tracking Number WASTE MANIFEST JJK 5 Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Generator's Phone. 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,_: U.S.EPA ID Number Facility's 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.Nol. 1. ti ,- _.u...._.... W i • t i s J 3: I , 4 _....._ -------- .... _...._.__,. 1 t i 14 Special Harding instructions and Additional informationw— -Zz7ma ,y-e'5--fir 1x j5 2" i 15. GENERATOR'SfOFFEROR'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. Generator /Offeror's Printed/TypedName Signature Month Day Year .:gip t -1 16.InternationalShipments F- ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Transporter signature(for exports only): Date leaving U.S.: 17.TransporterAcimowiedgment of Receipt of Materials Li Sj Transporter 1 PrinledfTyped•Name Signature ""; Month Day Year O • t ZZTransporter 2 Printed/Typed Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space Quantity ❑Type F1 Residue ❑Partial Refection ❑Full Rejection Manifest Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA ID Number 11 Facility's Phone: U t8c.Signature of Alternate Facility(or Generator) Month Day Year d Z 19.Hazardous Waste Report Management Method Codes(I.e.,codes for hazardous waste treatment,disposal,and recycling systems) p 1• 2. 3: 4. { y.! i 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printedffyped Name Signature Month Day Year , t EPA Form 8700-22(Rev.3-05) Pj'evious editions are obsolete. DESIGNATED FACILITY'S COPY