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Please print or type.ffoml designed for use On elite(12-plich)t pewriter.J 1.Generator ID Number Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS2.Page t of 3.Emergency Response Phone A.NfanHealTracking Number WASTE MANIFEST 5.Ge �S neralafs Name and Mating Address Ganeralofs Site Address(if different than mailing address) Ganeratofs Phone: 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA 10 Number 6,neslgnated Facility Name and Site Address U.S.EPA ID Number Facility's Phone: ga, 9b.U.S.DOT Description(including Proper Stdpong Name,Hazard Class,ID Number, 10Conratners HM and Packing Gmup(if any)) . 11.Total 12.Unit 13 Waste Codes 1 No. Type Quantity WLIVeI, g � 2. LU 70 r 3. { 4. 14.Special Handling Inst actions and Additional Information 15. G5N5RATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and aro classified,packaged, marked and labeledip€acarded,and are in all respects to 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 tNs consignment conform to the terms of the attached EPAAcknowledc ment of Consent I certify that the waste minimization statement identified in 40 CFR 262.27(x)(if I am a large quantity generator)or(b)(N am a small quantity generator)is true. GeretatofsfOfferar's PrintedlTyped Name SignatureMonth Day Year -J 16.inlemationalShipments ❑Impart to U.S. ❑Export from U,S Port of anlrylexiC Transporter signature(for exports only): Dale leaving U.S,: V.TransporterAcknoWedgmenI of Receipt of Materials Transporter 1 PrintedfTypad Name a Signature Month Day Year QTransporter 2 Primtedfryped Name Sognalure Month Day Year t- 18.Discrepancy 1 Be,Discrepancy indication Space Quantity ❑ pe T y El Residue ❑Par;sai Rejection ❑Full Rejection Manifest Reference Number. 18b.AitemateFacllily(arGeheretor) U.S.EPA ID Number V Facflitys Phone: LO 18c.Signature of Alternate FarJiiry(or Generelar} a Month Day Year Z F) 19,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) G 1 2' 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the marderst except as mted in Item 18a Print hyped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR