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Please print or type. (Form designed for use on elite (12-pitch) typewriter.) Form Approved. OMB No, 2050-0039 1 . Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number UWASiEMANAESOUS fX FLE 5. Generalors Name and Mailing Address Generators Site Address (if different than mailing address) 17 T . ' Nd 6 I , TTz, V0 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 Facilitys 9a 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10, Containers 11 . Total 12. Unit Hp51 and Packing Group (if any)) No. Type Quantity WtN01. 13. Waste Codes Q #I Z 2. w 3. 4. 14. Special Handling Instructions and Additional Information r, 15. GENERATOR'S(OFFEROR'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 labe'edlp',acarded, and are in all respects in proper condition for transport according to applicable intemational 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 EPAAcknoviledgment 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 t am a small quantity generator) is true. Generator's/Offerors PnntedlTyped Name Signature . Montha ear_ , J 16 , International Shipments ❑ Import to U .S. ❑ Export from U.S. Port of entry'trRi( z Transporter signature (for exports only): Dale leaving U.S.: w 17 . Transporter Acknovdedgment of Receipt of Materials ►— Tran er 1 P 'nte ed Name g e %I ) on a e e rL �` :} " n Transporter 2 Printed1Typed Name Signature Month Day Year 18. Discrepancy 18a . Discrepancy Indication Space quantity Type 1 ❑ El Partial Rejection El Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number J U w Facility's Phone: w 18c. Signature of Alternate Facility (or Generator) Month Day Year Q Z 19. Hazardous Waste Report Management Method Codes (i.e. , codes for hazardous waste treatment, disposal, and recycling systems) w i - r 2. 3. 4. 20 . Designated Facility 0°,vner or Ope�of: Certification of receipt of hazardous materials covered by the manifest exceptas noted in Item 18a PrintedlTyped Name ) f , SignatureMonth Day, Year EPA Form 8700-22 ( Rev. 3-05) Previous editions ate obsolete. — DESIGNATED D FACCLITY TOI GENERATOR