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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4 Manifest Tracking Number UNIFORM HAZARDOUS JJ K WASTE MANIFEST 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) Generator's Phone:= U.S.EPA ID Number 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name 8.Designated Facility Name and Site Address.- •, , , Jti U.S.EPA ID Number ''';�v� � -'r? •�'=M:=A&��.`,.�' .�-.�..fie.S f.i r ,+�,.r) �r."ii17-rs �.. ._�. .. .. :a �` � _ .:Mr. -'��" '%.:- .:r ',`�== 6-it;ry� .Sfff..+�i-ni-+�Y;:�17"r-, �'✓�7` + Facility's Phone: - ya 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. O Z 2• W _ CD 3. 4, 14.Special Handling Instructions and Additional Information =t? .3 ' �^�.tTfti? : 'E3 + ,. �'rl IT.r�l:i?,9rt•;Tr:�i tj.4 P1rfi,•F. `_ 7.1"C?t F7 t7 ,+_3`S_ I":tI''1f'ry +.f:jr'? i.%' ;}PPI"'Ci, u plr 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 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. certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if 1 am a small quantity generator)is true. Generalor'srOfferor's Printed(ryped Name Signature Month Day Year _j 116.International Shipments ❑Ex ort from U.S. Port of entry/exit: ❑Import to U.S. P z Transporter signature(for exports only): Date leaving U.S.: 17.Transporternow Acknowledgment of Receipt of Materials W Month Day„ Year"., Transporter 1 Printed/Typed Name Signature if k O a Q Month Day Transporter 2 Printed/Typed Name Signature Year F- 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: U.S.EPA ID Number 18b.Alternate Facility(or Generator) J_ V tai Facility's Phone: Month Day Year W 18c.Signature of Alternate Facility(or Generator) CDQ Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) W 1 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Month Day Year PrintedrTyped Name Signature _ EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY'S COPY