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4 P ease gritt or tyge. Form designed for use on elite 12- ltd. Form Approved. OMB No. 2050-0039 4 GENERATOR s .. UNIFORM HAZARDOUS WASTE MANIFEST 1. Generator ID Number 2, Page 1 of 3. Emergency Response Phc. U i 4. M8ife4t Trtickly 72 iti JJK Generator's Nome and Mailing Address Generatoes Site Address (if different than mailing address) Generators Phone: I Transporter 1 Company Name U.S. EPA ID Number Transporter 2 Company Name U.S. EPA ID Number I Designate,d 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 Of any)) No. Type Quantity Wt./Vol. 1 T I — - I I ----- Special Handling Instructions and Additional Information Jr 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, ard 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 1 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 lam a large quantity generator) or (b) (if I am a small quantity generator) is true. Generatoes/Offeroes Printed/Typed Name $ignature Month Day Year I I II -a I-' F- International Shipments Import to U.S. LI Export from U.S. Port of entry/exit: Transporter signature (for exports only): Date leaving U.S.: 'TRANSPORTER] Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day Year I I I Transporter 2 Pnnted/Typed Name Signature Month Day Year I I I I I ( DESIGNATED FACILITY --s Discrepancy 18a. Discrepancy Indication Space 7 Quantity Type Residue Partial Rejection Full Rejection Manifest Reference Number: 18b Alternate Facility (or Generator) U.S. EPA ID Number Facility's Phone: I 18c. Signature of Alternate Facility (or Generator) Month Day Year I I Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 1 2. 3. 4. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as ncted in Item 18a Printed/Typed Name Signature Month Day Year I I I I EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY