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s Please print or type. Form Approved. OMB No. 2050-0039 7 UNIFORM HAZARDOUS 1 . Generator ID Number 2. Page 1 of 3 Emergency Response Phone , 4 Manifest ack ng Number WASTE MANIFEST " _ z 5. Generator's Name and Mailing Address Generators Site Address if different than mailing address) 14 k Generator's Phone: 6 The nsporter_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: ` 9b. U.S. DOT Description (Including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Total 12. Unit 9a. 13, Waste Codes HM and Packing Group (if any)) No. Type Quantity Wt./Vol. a Wall Z 2 w 0 3 4. 14. Special Handling Instructions and Additional Information t — 15 "GENERATORSIOFFEROR'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 laceled/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 cemly that the waste minimization statement Identified in 40 GFR 262.27(x) (if I em a large quantity generator) or (b) (ifI am a small quantity generator) is true. Gators/Offerors Prnted7Typed Name Signature Month Day Year �. 16 International Shipments 1:1 Import toU.S. ❑ Export from U.S. Port of ntry/ext. '? Transporter signature (for exports only) Date Iasi U.S.: K 17 Transporter Acknowledgment of Receipt of Matenale Transporter 1 Prinled7Typed Nam Signature Month Day Year Z Transporter 2 PrintedlTyped Name Slipature Month Day Year h 18 Discrepancy ::: 18a Discrepancy Indication Space ❑ puantty ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number. 18b Alternate Facility (or Generator) U.S. EPA ID Number J U Facility's Phone' w 18c Signature of Altemate Facility (or Generator) Month Day Year a 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 3. 4. r 20 Des gnated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY