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Please print or type. Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1of 3.Emergency Response Phone 4.Manifes)Tr�kingg Ngmki DAT WASTE MANIFEST 10003E''12, ,i -19" 5.Generators 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 8.Designated Facility Name and Site Address U.S.EPA ID Number Facility's Phone: ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. z 2. w O 3. 4. 14.Special Handling Instructions and Additional Information 15. GENERATOR'SIOFFEROR'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 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)(if I am a small quantity generator)is true. Generators/Offerors Printed/Typed Name Signature ^ Month Day Year J 16.International Shipments ❑Import to U.S. F ❑Export from U.S. Irt of eritry/exit: ? Transporter signature(for exports only): Date leaving U.S.: tY 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day Year O a Z Transporter 2 Pdnted/ryped Name Signature Month Day Year 18.Discrepancy 1 Be-Discrepancy Indication Space ❑ Quantity ❑Type El Residue Partial Rejection ❑Full Rejection Manifest Reference Number: t tib.Alternate Facility(or Generator) U.S.EPA ID Number J U rai Facility's Phone: 18c.Signature of Alternate Facility(or Generator) Month Day Year a Z 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 Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY