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r t 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 j. _ .,..>.. ,s S Ilk K 5.Generator's Name and Mailing Address Generator'sSite 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'sPhone'� 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./Vol, ^ r L„ ! �,. 2 .N. Y 3. '¢} g I 4 s I 14.Special Handling?Instructions and Additional Information 154" '7 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 EPAAcknowiedgment 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. GeneratorlAfa ors Printed/Typedblame Signatures Month Day Year # e 7 r _t 16.International Shipments F ❑import to U.S. ❑Export from U.S. Port of entry/exit; Transporter signature(for exports only): Date leaving U.S. lx�LU 17.TransporterAcknowiedgment of Receipt of Materials 12 Transporter 1 PdntedfrypQ0,Narqe ;I Signature Month Day Year .r � 71 1 Transporter Printed/Typed Name Signature " Month Day Year 18,Discrepancy 18a.Discrepancy Indication Space 7 Quantity ❑Type ❑Residuejection El Full Re' ❑Partial Re lection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J V Facility's Phone: LU 18c.Signature of Alternate Facility(or Generator) Month Day Year 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) ,LU 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 Pdnted/'ryped Name Signature Month Day Year 6 , EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY'S COPY