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Please print or type. Form Approved,DMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Man lfestTr'_acking Number [[�� WASTE MANIFEST i.; VE 5.Generators 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(induding Proper Shipping Name,Hazard Class,ID Number. 1 D.Containers 11,Total 12.Unit 13.Waste Codes HM and Packing Group(if any)] Na. Type Quantity Wt.Nol. 1- O W 0 3. 4. 14,Special Handling instructions and Additional Information 15. G£NERATOR'SiOFFEROR'S CERTIFICATION: I hereby declare that the contents of this oon*nment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labeledfplacarded,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 EPAAckrwwledgment of Consent. I certify that the waste minimization statement identified in 46 CFR 262.27(a)(if I am a large quantity generator)or(b)(if l am a small quantity generator)is true. Generato Wffisror's PrintedrTyped Name Signature Month Day Year j 16-international Shipments ❑Import to U.S- ❑Export from U.S. Pal of entrylexiF. Z Transporter signature(tor exports only); Date leaving U.S.: W 17.TransporterAcknowtedgment of Receipt of Materials Transporter t Printed/Typed Name Signature Mordh Day Year ZTransporter 2 Printed/Typed Name Signature Month Day Year 18.Discrepancy 1 Ba,Discrepancy Indication Space Quantity El Type El Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number, 18b,Alternate Facility(or Generator) U-S.EPA ID Number V Facilittfs Phone: W lac.Signature of Alternate Fadlity(or Generator) Month Day Year a a N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) G 1. 2. 3- 4. 20.Designated Facility Owner or Operator:Cenification of receipt of hazardous materials covered by the manifest except as nda l in Item 180 Printedlfyped Name Signature Month Day Year EPA Form 8700-22[Rev.12.17] Previous editions a°e obsolete. GENERATOR'S INITIAL COPY