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Please print or UNIFORM HAZARDOUS 1 1 Form Approved,OMB No.2050-0039 Generator IO Number 2.Page 1 of 3.Emergency Response Phone 4.Men eat Tracking Number WASTE MANIFEST JJ K 5.Generator's Normand Mailing Address Generator's Site Address(d different than mailing address) Generators Ph e:; 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Nemo U.S.EPA ID Number S.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 Gass,ID Number, 10.Containers 11•Total 12.Unit HM and Packing Group(ff any)) No. Type Quantity Wt.Nol. 13.Waste Codes C ; 0 3. j 1 4. 14,Special Handling Ins1ruc tions and Additional Information 15. GENERATOR'SfOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,ard are classified,packaged, marked and labeledlplacarded,and are In all respects In proper condition for transport according to applicable intematicnal and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the oD*nts 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)(ifl am a small quantity generator)is true. Generator'slOfferors PdntedlTyped Name Signature Month Day Year a 16.IntemaMiai Shipments F- ❑Impo4 to U.S. ❑Export tram U.S. Port of entrylexit: ? Transporter signature(for exports only): — W 17.TrarepoterAaknowl Date leaving U.S. edgmeni or Receipt of Materials OTransporter 1 Pdntedrryped Name Signature Month Day Year a , Z Transporter 2 Prirted/Typed Name Sgnature Month Day Year OHC 18.Discrepancy laa.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑full Rejection 1 ab.AlienManifest Reference Number:ate Facility for Generator) U.S.EPA ID Number V t� Facility's Phone: w 18c.Signature of Altemate Facltity(or Generator) Month Day Year a z w19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) im 1. 2. 3. 4. 20,Designated Facility Owner or OperaW.Certification of receipt of hazardous materials covered by the manifest except as nded in Item 18a PrintaCyped Name Signature Month Day Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY