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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 1 of 3. Emergency Response Phone 4, Manifest Tracking Number p WASTE MANIFEST G B F 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 . 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 (including Proper Shipping Name , Hazard Class, ID Number, 10. Containers 11 . Total 12 , Unit HM and Packing Group (if any)) No. Type Quantity Wt.Nol. 13. Waste Codes i . O Z 2. W 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 classified, packaged , marked and labeledlplacarded , 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 EPAAcknoWedgment 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. Generatorsl0fferors PrintedlTyped Name Signature Month Day Year H16. International Shipments ❑ import to U .S. ❑ Export from U.S. Port of entry/exit: Transporter signature (for exports only): Date leaving U.S.: w 17. Transporter Acknowledgment of Receipt of Materials a Transporter 1 PrintedlTyped Name Signature Month Day Year O QTransporter 2 Printed/Typed Name Signature Month Day Year H 18. Discrepancy 18a , Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue El Rejection El Full Rejection Manifest Reference Number: 18b, Alternate Facility (or Generator) U.S. EPA ID Number J U Facility's Phone: Lu 18c. Signature of Alternate Facility (or Generator) Month Day Year Z C9 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) U) Wo 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 Printedfryped Name Signature Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete . i