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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 1 Generator ID Number 2.Page 1 of 3.Emergency Response Phon 4.M 'fast T cking Nu,bar UNIFORM HAZARDOUS g tf>�tx 'S,' d .3 aalff WD TE MAW,'FEST 5.G„watOr'sName antl Ma l(ngAddress Generator's Sb Address(if 'dt than mailing address) s; .( Generators Phone 6.Trans orter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.DesignatedPacilfty Name and Sde 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. Ty ed Quantity Wt.Nol. ®UJ 2. 3 . . .. 4.:. 14.Special Handling Instructions and Additional Information A 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately describedve 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 go mental 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 quan generator)is true. Month Da Year Generators( ererissPnntedlTyped Name ry Signature Y �r uro 116,Internatiotta r ents P ri to S: ❑Export fr601TU-S: " g •Port of entry/exit: z Transporter signature(for exports only): r' Date leaving U.S. w 17.TransporterAcimowledgment of Receipt of Materials f Transporter'1Printed/ryped Name t,a 9igfiature Month Day Year ® s QTransporter 2 Printedrryped Name Signature Month Day Year 18.Discrepancy 18a,Discrepancy Indication Space ❑ quantityyp J ❑T e 11Residue 0 Partial Rejection ❑Full Rejection Manifest Reference Numb 18b,Alternate Facility(or Generator) U.S.EPA ID Number J Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year Q ' Z ' y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LIJ0 1. 2. 3. L L 1 4. 1 1 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.3-05) Previous editions are obsolete. AT " INITIAL `