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Please print or type. (Form designed for use ort elite (12-pitch)typewriter. ERATOR I. I UNIFORM HAZARDOUS WASTE MANIFEST 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number JJK 5 Generatoi's Name and Mailing Address Generator's Site Address (if different than maNing address) Generators Phone: I Transporter 1 Company Name U.S. EPA ID Number I Transporter 2 Company Name U.S. EPA ID Number I Facili Designated Facility Name and Site Address U.S. EPA ID Number y's Phone: I ga. 9b. U.S. DOT Description /including Proper Shipping Name, Hazard Class. ID Number, 10. Containers 11, Total 12. Unit A and Packing Group (if any)) No. Type Quantity WINO!. 13. Waste Codes 1. 4 GEM ...... I 14. Special Handling Instructions and Additional Information -:- .k. . . _ .1. tAi. i'..' ... t•1: GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully arid accurately described above by the proper shipping name, and are classified, packaged, marked and letelediplacarded, 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 certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I urn a large quantity generator) or (b) (if I am a small quantity generator) is true. Generator's:Offerors Printed/Typed Name Signature Month Day Year I I I I —I r— M International Shipments Import to U.S. Export from U.S. Port of entry/exit: Transporter signature (for exports only): Date leaving U.S.: TRANSPORTER Transporter Acknowledgment of Receipt of Materials TtAniporter 1 Printed/Typed Name Signature Month Day Year I I I I Transporter 2 Printed/Typed Name Signature Month Day Year I I I I I ' DESIGNATED FACILITY --0- IS. Discrepancy 19a. Discrepancy Indication Space Quantity LI Type LI Residue Partial Rejection LI Full Rejection Manifest Reference Number: Vt. Alternate Facility (or Generator) U.S. EPA ID NumPer Facilitys Phone: I 1Bc. Signature of Alternate Facility tor Generator) Month Day Year I I 19. Hazardous Waste Report Management Method Codes ):.e., codes for hazardous waste treatment, disposal, and recycling systems) 1. 2. 3. 4. 20 Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrintediTyped Name Signature Month Day Year I I I I EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR