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Please print or type. (Form designed for use on elite (12-pitch) typewriter.) Form Approved. EMS No, 20500039 UNIFORM HAZARDOUS 1 GeneralorlD Number 2 Page .9of 3 Emergency Response Phone 4 Manifest Tracking Number WASTE MANIFEST G B F 5. Generators Name and Mailing Address t Generates Site Address (ddifferent than mailing address) Generators Phone: 6. Transporter 1 Company Name U.S. EPA ID Number 7. Transporter 2 Company Name U.S. EPA ID Number 1 B. Designated Facility Name and Site Address US: EPA ID Number Facility's Phone: - 9a, 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 134 Waste Codes HM and Packing Group (if any)) No. Type Quantity WI,NoL OQ W 2 2, W 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 expel 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, Generalor'sl0fferors PrintedlTyped Name Signature % Month Day Year ) 1 i r j I 16. International Shipments F El Import to U,S. ❑ Export from U.S Port of ntrylexit: z Transporter signature (for exports only): Date leaving U.S.: w 17. Transporter Acknowledgment of Recelpt of Materials Transporter 1 Printed/Typed Name Signature Month Day Year ai n Transporter Printed/Typed Name Signe(ure' Month Day Year 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantic Type Quantity El El Residue ❑ Partial Rejection E] Full Rejection Manifest Reference Number 1 Bb, Alternate Facility (or Generator) U.S. EPA ID Number U ua- Facility's Phone: us 18c. Signature of Alternate Facility (or Generator) Month Day Year Q Z N19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) l 14 f a 24 3. 4. 20. Designated Facility Owner or Operate Certification of receipt of hazardous materials covered by the manifest except as noted in Item Ise Printedrfyped Name Signature Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete.