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Received by EHD 9/19/2025 F'jease print or type. Form Approved.OMB No,2050-0039 1,Generator ID UNIFORM HAZARBOIiS Number 2.Page 1 of 3.Emergency Response Phone 4 Manifest Tracking Namger WASTE MANIFEST 5 S.Generator's Name and Mailing Address LE Generatcr's Site Address{!f different than mailing address) Generator's Phonc: 6.Transporter 1 Company Name U.S.EPA ID Num or 7 Transporter 2 Company Name U.S.EPA ID Number 8.Designaled Facility Name and Site Address U.S.EPAlD Numbe{ Facility's Phone: ga 96.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.TDtai 12.Unit HM and Packing Group(if any)) No. Type Quantity wt,NDl. 13.Waste Codes nz} a 7 LM 1 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 fabeledlpiacarded,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 EPAAcknowledgment of Consent, i certify that the waste minimization statement identified in AO CFR 262.27(a)(if I am a large quantity generator)or(b)(ifl am a small quantity generator)is true. Gerreralar`slOfferoes Pdnted/Typed lame 81gnature ... Month Yearf __j 16.IntemaBanal Shipments z ❑Import to U.S. ❑Export from U.S. Port of entrylexit: Transporter signature(far exports only): Date leaving U.S.: w 17.TransporterAcknowledgment of Receipt of Matertals Transporter 1 PrintetllTyped Name Signature Month Day Year Transporter 2 Printed/Typed Name Signature Month Day Year F 18.Discrepancy 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Fu[I Rejection 18b.Alternate Facility{or Generator} Manifest Reference Number; U.S. PAID Number J L> 9 Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) a Month pay Year 1 9.Hazardous waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 2. 3. 4. 20.Designated FaciAry Owner or Operator:Cartification of receipt of hazardous materiats covered by the manifest except as nded 0 Item 1 Be PrintedlTyped Name Signature Month qay Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY