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Please print or type. (Form designed for use on elite ( 12-pitch) typewriter.) Form Approved. OMB No. 2050.0039 UNIFORM HAZARDOUS 1 . Generator ID Number 2 Page i of 3. Emergency Response Phone 4. Manifest Tracking Number WASTE MANIFESTFLE 5, Generator's Name and Mailing Address Generator=s Site Address (if different than marling address) fitlow s e: 6. Transporter 1 ConTffl1yNVdftV U.S. EPA ID Number AdOWAW MWWOWTra"Od kw* KV) CAMM70W 7, Transporter 2 Company Name U.S. EPA ID Number , . ai 4A 8. Designated Fatality Name and Site Address U.S. EPA ID Number OW T C - asp e: ga 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 any)) No. Type Quantity WI-Nal. Cr XON RCRA 14AZARMUS M SOI : W8 _� AND Nu z 2 . C7 3, E 14, Special Harding instructions and Additional informafion y 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are Fu"sly and accurately described above by the proper shippiN name, and are classified, packaged, marked and tabeiedipracarded, and are in all respects in proper condition for transport according to appl=cable international and national governmental regulations- it export shipment and I am the Primary Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I certify that the waste msnimization 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. Ge,i atoeslOfferces Prnnted!Typed Name Signature Month 1)ay��ear 16 International Shipments a Import to U ,S. El Export from U .S. Part of entry/exit Transporter signature (for exports only): Date leaving U -S,: 17. Transpoder AcliLwMedgmenI, of Receipt of Materials e Trans er 1 Prntedliyped Names Signator p 1 Ii4onth Day Year m. . ( q I Transporter 2 Pimlied Typed Name S gnature Month Day Year r , 18. Discrepancy 18a, Discrepancy Indication Space ❑ ouamity Type ❑ Resdue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U .S. EPA ID Number J_ U Q �- Facility's Phone: 18c. Sionature of Alternate Facility (or Generator) Month Day Year Q Z N19, Hazardous Waste Report Management Method Codas (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 1 . 2. 3: 4, 20. Designated Facility Oar°ner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrintedtTyped Name f Signature Month Day Year �ty At rr i EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR