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Please print or type. 111111111 IN Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS I".Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST 013655943 FLE 5.Generator's Name and Mailing Address Generator's 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 r _ 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 Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) 13.Waste Codes No. Type Quantity Wt.Nol. 1. O z 2. L c9 3. 4. 14.Special 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,arra 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 EPAAcknowledgmen Consent. certify that the waste minimizatio statement identified in 40 CFR 262.27(a)(if I am a large quantity generator) (b (if I am a small qu ner is true. G nerator's/Offeror's Pri ayped am nature Month Day Year � v J 16.International Shipments j... ❑IMPo U.S. ❑Exportfro . . Port of entry/exit: ? Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials LLI Transporter 1 Printed/Typed Name Signal Month Day Year O 1 1 z Transporter 2 Printed/Typed Name ,�: nature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space Quantity El Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J_ V LL Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z as19.Hazardous Waste Report Management Method Codes(Le,,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 manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM