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Please print or type. Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4 ")fest Traalung,Nuptber WASTE MANIFEST "; 1 VES 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 U.S.EPA ID Number r A T 0 0 0 6 3 4 2 4 7 e.Designated Facility Name and Site Address U.S.EPA ID Number 3 ^7 Facility's Phone: iZqj 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)) Na. Type Quantity W1.Nol. 1. tY - O W z 2. W C7 3. 4. 14.Special Handling Instructions and Additional Information 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this oonsignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labelediplacarded,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 EPAAcknowledgment 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. GeneratorslOfferors Printed/Typed Name Signature Month Day Year J 15.Intematonat Shipments F ❑Import to U.S. ❑Export from U.S. Port of entrylexit: z Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials LU Transporter 1 PrintedlTyped Name Signature Month Day Year z Transporter 2 Printedrryped Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity Type yp 11Residue ElPartial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J_ ILL V Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year a Z rn19.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 PrintedlTyped Name Signature Monlh Day Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY