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t`y please print or type. . Form Approved. OMB No. 2050-0039 UNIFORM HAZARDOS1 GeneratorID Number 2. Pa9e. 1 of 3 Emergency Response Phone 4 Manifest Tracking 9Number WASTE MANIFEST . _ ,. ._ . ,.. ,,. , t U -.,7, SKS 6 Generators Name and Mailing Address Generator's Site Address (if different than mailing address) l Generator's Phone: 6. 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: ' ga go. 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)) No. Type Quantity 12, Unit ;t 1 � .v K W W 2 U' 3 4. 14 Special Handling Instructions and Additional Information 11 : 15 GENERAiOR'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 andiabeletl/placarded, 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 EPA Acknowledgment of Consent. I certfy that the waste minimization statement Identified in 40 CFR 262.27(a) (I4I am a large quantity generator) or (b) (ifI am a small quantity generator) Is true. Gepdratoesl0fferofs Prnted/Typed Name Signature Month Day Year � 18 International Shipments �, 11 Import to U.S. EJ Expert from U.S. Pori of entry/exit z: Transporter signature (for exports only): Date leaving U.S.: W 17, Transporter Acknowledgment of Receipt of Materials Transporter Prnted//Typed;Name Signature Month Day Year IS QQ:. Transporter 2 PrintedlTyped Name Signature Month Day Year I- 18 Discrepancy 18a Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: 18b Alternate Facility (or Generator) U.S. EPA ID Number U LL Pacltys Phone w 18c. SgnatureofAlternate Facility (or Generator) Month Day Year Z N19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) Q 1 . 2. 20 Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Pnnted/Typed Name Signature Month Day Year EPA Form 8700-22 (Rev., 12-17) _Previous editions are obsolete. GENERATOR'S INITIAL COPY