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Please print or type. aryl Form Approved. OMB No. 2050-0039 } UNIFORM HAZARDOUS 1 . Generator ID Number 2. Page 1 of 3 Emergency Response Phone 4 M mfest T k g Number WASTE MANIFEST - _ sSKS " 5. Generatofs Name and Mailing Address Generator's Site Address (if different than mailing address) Generator's Phone: 6. Transpoper,l Company Name U.S. EPA ID Number 7. Transporter 2 Company Name U.S. EPA ID Number 8.Designated Facility Name and Site Address - U.S. EPA ID Number Feel a Phone: _ ( fib. U.S. DOT Description ncludin Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Total 12. Unit 9a. (including pp' g 13. Waste Codes i> HM` .. end Packing Group (If any)) No. Type Quantity Wt.Nol. C 1 O Q K Z 2 w r � , 3 4. ', 3 14 Special Handling Instructions and Additional InformationI r7 - 1 15f GENERATOR'SIOFFEROR'S CERTIFICATION: (hereby declare that the contents oft his consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, marked and tapeledlplacarded,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 Hie contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. pertly that the waste minimization statement Identified in 40 CFR 262.27(a) (If I am a large quantity generator) or (b) (dl am a small quantity generator) is true. G nerator'sfOfferors PnntedlTyped Name Signature Month Day Year , 16,Internat oral Shipments ❑ Import to U.S. ❑ Export from U.S. Pon of entrylexit: Z Transporter signature (for exports only) Date leaving U.S.: W 17 Transporter Acknowledgment of Receipt of Materials a Transporters PrintedfTyped Name Signature -� Month Day Year a . aza Transporter FPdnted/Typed Name Signature Month Day Year °< 18 Discrepancy „ 18a Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number. 181 Alternate Facil ty (or Generator) U.S. EPA ID Number U w . Facltys Phone Month Day Year w 18c. signature of Alternate Facility (or Generator) z w19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 0 12. 3. 4. � 20 Designated Fac tity Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a . PnntedffypetlName Signature Month Day Year a EPA Form 8700-22(Rev. 12-17) ,Previous editions are obsolete.