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1r< Ptease pmk or type. Form Approved. OMB No. 2050-0039 UNIFORM HAZARDOUS 1 Generator ID Number 2 P:irage 1 of 3 Emergency Response Phone 4 Manifest Tracking Number �p WASTE MANIFEST SKS 5. Generator's Name and Mailing Address Generator's Slte Address (If different than mailing address) Generator's Phone: 8 Transporter 1 ,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 Facility's Phone: 9a 91 . U.S. DOT Descnptlon (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Total 12. Unit 13. Waste Codes HM and Packing Group (if any)) No. Type Quantity Wt.Nol. i I ; w Z 2 w U' 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 Iabeledlplacarded, 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:cart ly that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I cemfythat 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. Generator's/Offerors Pnntedfryped Name Signature Month Day Year k° 16. International Shipments [I Import to U.S. ❑ Export from U.S. Port of entry/exit: ?. Transporter signature (for exports oMy) Date leaving U.S.: W 17 Transporter Acknowledgment of Receipt of Materials TTnsporter1 PrintedrTyped Name t Signature Month Day Year a ! Z Transporter 2Printedfryped Name Signature Month Day Year Q 18 Discrepancy 18a Discrepancy Indiczhon Space ❑ quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: 18b Alternate Facility (or Generator) U.S. EPA ID Number J Lo LL Facl gna tys Phone Month Day Year w 180 StureofAlternate Facility (or Generator) ` z 19 Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) ca 1 2. 3. 4. 20 Designated Fadlity Owner or Operator Cert fcation of receipt of hazardous materials covered by the manifest except as noted In Item 1Ba Pnnted/Typed Name Signature Month Day Year I , GENERATOR'S IM9TIAL ®PY . EPA Form 8700-22 (Rev 12-17) Previous editions are obsolete.