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Please print or type. Form Approved, OMB No. 2050039 UNIFORM HAZARDOUS 1 . Generator ID Number 2, Page 1 of 3. Emergency Response Phone 4 Manifest Tracking Number WASTE MANIFEST a + J J K 5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) Generator's Phone: 6. Transporter t 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: 93. 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 WLNol. L _ O Z 2, W C� 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 labeled/placarded, and are in all respects in proper condition for transport according to applicable intemational 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) (1fl am a small quantity generator) is true. Generators/Ofieror's 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 Transporter 1 Printed/Typed Name Signature ; Month Day Year O a z Transporter 2 PrintedlTyped Name Signature Month Day Year 9 t- 18. Discrepancy 18a. Discrepancy indication Space 0 Quantity ❑ Typej j ❑ Residue Partial Rejection ElFuli Rejection Manifest Reference Number: 16b. Alternate Facility (or Generator) U.S. EPA ID Number J U W Facility's Phone: w 18c. Signature of Alternate Facility (or Generator) Month Day Year tE Z 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) a1 . 2. 3. Notice : State of California requires generator to photocopy and mail to 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item Printedrryped Name Signature ar EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. GENERA ORIS iNl.j IA GO Y