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Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) Form ADDroved. OMB No. 2050-0039 EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY UNIFORM HAZARDOUS 1. Generator ID Number 2. Page I of 3. Emergency Response Phone 4. Manifest Tracking Number WASTE MANIFEST FLE 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 B. Designated Facility Name and Site Address U.S. EPA ID Number Facility's Phone: 9a 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))13. Quantity WLNoI. Waste Codes No. Type OF - - j Z 2. W 3. I 4. I T4—Sp ecal Handling Instructions and Additional Information 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 labeled/placarded, 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 EPAAcknowiedgment 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. Generator's/Offeror's PrinledfTyped Name Signature Month Da—y--Tea—,— I i i, ° I i i i— 16 International Shipments ❑ Import to U.S. ❑ Export from U.S. Port Z of entry/exit: Transporter signature (for exports only): Date leaving U.S.: (If 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 PrintedfTyped Name Signature Month Day Year ZTransporter 2 Prinledfiyped Name Signature Month Day Year r 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity El Residue Partial Rejection ❑ Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number J U Q Facility's Phone: w 18c. Signature o(Allernale Facility (or Generator) Month Day Year Q z 0 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 0 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. GENERATOR'S INITIAL COPY