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f 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 1 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST J' J J K 5.Generator's Name and Mailing Address Generators Site Address(if different than malling address) i Generators Phone:.i':. 6.Transporter 1 Company Name U.S.EPA ID Number i 7.Transporter 2 Company Name U.S.EPA ID Number B.Designated Facility Name and Site Address U.S.EPA ID Number Facility's Phone:'I" 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Ulr HM and Packing Group(if any)) No. Type Quantity A'fNoi 13.','Jaste Ludas 0 � 2. W 0 3. 4. 14.Special Handling Instructions and Additional Information IdAND EPS 15. GENERATOR'SJOFFEROR'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 labelediplacarded,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 EPAAcknowledgment 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! enerator)Is true. GeneralorsJOffergr4 Pdotar.Jiyp<id Name Signature Month Day Year . 16.Inlemational S Ipmenls ) F- ❑Import to U.S. Export from U.S. Port of eptrylexil: Transporter signature(for exports only): Date leaving U.S 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 PrinlaVyped Name Signature Month Day Year Q7fler 2 PKIIECUTjVEd Name Signature Month Day Year a F- 1B.Discrepancy 18a.Discrepancy Indication Space [:1 Quantity U PfI ❑Residue ❑Partial Rejection Full Rejection Manifest Reference Number. 181b.Alternate Facility(or Generator) U.S.EPA ID Number V Facility's Phone: W 1Bc.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) A 1 2, 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a rn;7tedrTyped Nae Signature Month Day Year EPA Form 8700-22(Rev.`!J, 05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR