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Please pnnt or type (Form designed for use on elite(12-pitch)typewriter.) Fort Approved OMB No.2050-0039 UNIFORM HAZARDOUS 1 Generator ID Number 2 Page 1 of 3 Emergency Response Phone 14.Manifest Tracking Number WASTE(MANIFEST _ JJK 5 Generator's Name and Mailing Address V Generators sileAddress(if different than mailing address) Generator's Phone. . 6 Transporter 1 Company Name U.S.EPA ID Number r. 7.Transporter 2 Company Name U.S.EPA fO Number 8 Designated Facility Name and Site Address U.S.EPA ID Number Facility's Phone 9a 9b U.S.DOT Descnpton(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(d any)) No. Type Quantity W1Nol. 13.Waste Codes 1 INN ., Z 2 !u t7 ' 3 ) i 1 S 4 p I 14 Special Handling Instructions andAdditlona)Information 15. GENERATOR'SIOFFEROR'S CERTIFICATION 1 hereby declare that the contents of this consignment are fulfy and accurately described above by the proper shipping name,and are classified,packaged, e marked and Iabeledlpiacarded,and are in all respects in proper condition for transport according to applicable international and national govemmental regulations If export shipment and I am the Pnmary 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 generator)is trus Generator's/Offerors Printed/Typed Name Signature Month Day Year 16 International Shfpments ❑Importto U.S ❑Export from U.S. Port of entiylexd,, Transporter signature(for exports only) Date leaving U.S LU 17 TransporterAcknowledgment of Receipt of Materials Transporter 1 P ted7Typed Name Signature, -x O q 4 t g { Month Day. Year 0. ' Transpotktrinledffyped Name i Signature Month Day Year F 18.Discrepancy 18a Discrepancy indication Space Quantity ❑Type yP ❑Residue ❑Partial Rejettlon ❑Full Refection 18b Alternate Reference Number. ate Facility(or Generator) U.S.EPA ID Number _J V Facility's Phone W 18c Signature of Afternaie Facility(or Generator) a Month Day Year Z C, 19 Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) p 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 PrintedfTyped Name Signature Month Day Year EPA Form 8700.22(Rev 3-05) Previous editions are obsolete GENERATOR'S INITIAL COPY