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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 (' (� WASTE MANIFEST G B F 5. Generator's Name and Mailing Address Generators Site Address (if different than mailing address) Generator's Phone: 6, Transporter 1 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 WtJVo13. Waste Codes h LLI i . d Z 2. W O 3 1r " A 14. Special Handling Instnctipns06dAdditonaUnformaron 1 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 EPAAcknowledgment 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. Generators/Offerors Printed/Typed Name Signature Month Day Year . i 16. International Shipments H ❑ Import to U .S. ❑ Export from U.S. Port of entry/exit: Z Transporter signature (for exports only): Date leaving U.S. : UJ 17 . TransporterAcknovdedgmenlofReceiptofMaterials Transporter 1 Printed/Typed Name Signature Month Day Year O cn Z Transporter 2 Pfinted/Typed Name Signature Month Day Year 18. Discrepancy 18a . Discrepancy Indication Space El Quantity ❑ Typej j ❑ Residue El Partial Re eclion Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U .S. EPA ID Number J v Facility's Phone: uu 18c. Signature of Alternate Facility (or Generator) Month Day Year Q 19. Hazardous Waste Report Management Method Codes (i.e , codes for hazardous waste treatment, disposal, and recycling systems) W 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 PrintedrTyped Name Signature Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete .