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Please print or type. (Form designed for use on elite UNIFORM HAZARDOUS 1. Generator ID Num WASTE MANIFEST 5. Generator's Name and Mailing Address ;ch) typewriter.) Form Approved. OMB No. 2050-0039 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number Generator's Site Address (if different than mailing address) ~ i U.S. EPA ID Number U.S. EPA ID Nurnber 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 HM and Packing Group (if arty)) No. Type Quantity Wt.A%ol. 0 Z 2. UJ ;r; :s• C9 3. 4' 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 classinea, 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, l 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 (b) (if I am a small quantity generator) is true Generator's/Offeroes Printed/Typed Name Signature Month ! Day Year a 16. International Shipments F— ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit:_-- z Transporter signature (for exports only): Date leaving U.S.: 17. Transporter Acknowledgment of Receipt of Materials W I � Transporter 1 Printed(fyped Name _,Y Signature Month Day Year - rL O (nmA.. Month Day Year Q Transporter 2 Printed/Typed Name Signature j 18. Discrepancy Ell — 18a. Discrepancy Indication Space El Quantity ❑ Type D Residue ❑ Partial Rejection E Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number Facility's Phone: -- 18c. Signature of Alternate Facility (or Generator) Month Day Yea 2 y19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) UJ 1 2' 3. A. 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. iJESlGt A T ¢ 1; IFIN 1`