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Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) Form Approved. 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 1 of 3. Emergency Response Phone 4. M)?nifestTracking Number. WASTE MANIFEST FLE 5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) Generators 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: 9a. 9b. U.S. DOT Descriplion (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit HM and Packing Group (if any)) Quantity Wt.Nol. 13. Waste Codes No. Type O W Z LUO 2. l 3. i t 4. t i 14. Special Handling Instructions and Additional Information 15. GENERATOR'S10FFEROR'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 allached EPA Acknowledgment 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) (it I am a small quantity generator) is true. Generator'srOf(eror's Printedrryped Name Signature on ay Year (�'If lei! -►;4'i10!! i. ,. J z 16. International Shipments ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: Transporter signature for exports only): Dale leaving U.S.: w 17. Transporter Acknowledgment of Receipt of Materials b� Transporter 1 Prinledrryped Name Signature Month Day Year O a zTransporter 2 POnled/Typed Name Signature Month Day Year H 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity Type Residue Partial Rejection ❑Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number J U Q L- Facility's Phone: D 18c. Signalure of Alternate Facility (or Generator) Month Day Year Q Z F) 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 Printedrryped Name Signature Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY