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Please print or type. Form Approved , OMB No. 2050-0039 UNIFORM HAZARDOUS 1 , Generator ID Number 2 . Page 1 of 3. Emergency Response Phone 4, Manifest Tracking Number � � WASTE MANIFEST O V 8 02 " t 1 5. Generator's Name and Mailing Address Generators Site Address (if different than mailing address) 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 i t t , t� U .S . EPA ID Number #l�k+l; iti . Lit � � i t t.kik 1 L; 'U , 1500 LUKt.:ORN QUAD st ia1 •• l � �� :wti :: Facility's Phone : ya 9b. 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 Wt.No1 . I 1 ' 1i i Ot t � ? : � t 1 . f. F r? 1 ` . CI-IF` t)F+ !. ?- ►;� ,, F ' n� , :i b I LU 2. w i i 3 . 4 I I i i 14 . Special Handling Instructions and Additional Information 1 iitt > }}s {j:Sk'sft1C�? 3S L 1 aN ttiL760 L.HiSKiT 1 Lalvtrar_ t reta ; fiea by qr;; $' ;^ T; :: } ;15"1` .+ � ` : i i7rpr; f', '" fil3 ';'1 ;: �; t 4.R'f. F`- r4fjF'' ?. C- 6AI 15. GENERATOR'S/OFFEROR'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 labeled/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 certify that 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 . Generators/Offerors Printed/Typed Name Signature Month Day Year 16, International Shipments ❑ Import to U .S. ❑ Export from U .S. Port of entrylexit: ? Transporter signature (for exports only) : Date leaving U .S. : W 17, Transporter Acknowledgment of Receipt of Materials w Month Da Year � Transporter 1 Printed/Typed Name Signature y O N Signature Month Day Year Z Transporter 2 Printed/Typed Name 9 F- 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 Facility's Phone: W 18c. Signature of Alternate Facility (or Generator) Month Day Year Q z N19, Hazardous Waste Report Management Method Codes (i .e. , codes for hazardous waste treatment, disposal , and recycling systems) LLI 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 Printed/Typed Name Signature Month Day Year EPA Form 8700-22 (Rev . 12- 17) Previous editions are obsolete . GENERATOR' S INITIAL COPY