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Form Approved. OMB No. 2050-0039 rlease pma ui typo. trunu ucaiynU. — uac — t — F, .yr,,.., ,- 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tr acking Number UNIFORM HAZARDOUS i JJ K WASTE MANIFEST 5. Generator's 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 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 (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes No. Type I -IM and Packing Group (if any)) Quantity Wt.Nol. 1. o% O Z 2. LU C:1 3. c 4. i� 14. Special Handling Instructions and Additional Information 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. I t 1 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. Generator's/Offeror's Printed/Typed Name Signature Month Day Year j F_ 16. International Shipments El import to U.S. ❑ Export from U.S. Port of entry/exit: Transporter signature (for exports only): Date leaving U.S.: 17. Transporter Acknowledgment of Receipt of Materials Uj Transporter 1Printed/Typed Name -.- - •- Signature Month Day Year - y c1111 i. a) ;7 Signature Month Day Year Transporter 2 Printed/Typed Name 9 or i� f 18. Discrepancy 31 I 18a. Discrepancy Indication Space❑Quantity ❑Type El Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number U LL 2 Facility's Phone: 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) 0 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 _ Printed[Typed Name ' Signature Mot Day Year EPA Form 8700-22 (Kev. 3-uo) rrevious eamons are ousuiete.