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Fiease print or roe. (i-orm cesigneG Tor use on eite k I Z-P[[Gn) LypeWrKer.) UNIFORM � AZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number WASTE MANIFEST JJK_ 5. Generators Name and Mailing Address Generator's Site Address (if different than mailing address) Generator's Phone: 6. Transporter I Company Name U.S 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: 9a. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10, Containers 11. Total 12. Unit 13. Waste Codes No. Type HM and Packing Group (if any)) Quantity Wt./Vol. T 0 LJ 3. W; T IE F L. M NA P. LE t, 7 D k I P °SCF. I ONE 4 1 J, 'i 111 ;'.l 14. Special Handling Instructions and Additional Inforyatio RO -. ,7 T It V[ L. Cl 24HIk P TF -H I NO 15, GENERATOR'S/OFFEROR'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 certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (h) (if I am a small quantity generator) is true. rn—erator's/Offeror's Printed/Typed Name Signature Month Day Year _J l 16. International Shipments D Import to U.S. El Expert from U.S. Port of entry/exit: 3 Transporter signature (for exports only): Date leaving U.S.: LWI Ll 17. Transporter Acknowledgment of Receipt of Materials Transporter'( Printed/Typed Name Signature Month Day Year 0 Z Transporter 2 Printed/Typed Name Signature Month Day Year 18. Discrepancy 18a. Discrepancy Indication Space El Quantity El Type El Residue ElPartial Rejection ❑ Full Rejection Manifest Reference Number: G W'R W 18b. Alternate Facility (or Generator) U.S. EPA ID Number LL Facility's Phone: w18c. Signature of Alternate Facility (or Generator) Month - Day Year !R BY: Z ....................... 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 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 Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete.