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J rJ v T„ Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4 Manifest Tracking Number a : WASTE MANIFEST . s GBF 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Generator's Phone:]_y- 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 U.S.EPA ID Number �. jr a...k:,iL3'i:�:r vs P�c�traUrt, •.L Facility's Phone: ga. 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.Nol. cc1 � e — W Z W 0 I I I � GENT has the appropriate RE ErAN permits for and will acce ' VIZU 4. the waste this generator i I _ shipping. - 14.Special Handling Instructions and Additional Information ENVIR _" . ......� 4. E�F.4.TN►1FPr7gTAAFf\1T .:�Z i ,-. 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. 1 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 4small quantity generator)is true. Generator's/Offeroes PrintedlTyped Name ,.�. Signature_ �. , t r Month Day Year i 16.Intemation rpments" ' Z 11 Import to U.S. ❑Export from U.S. Port of entry/exit: Transporter signature(for exports only): Date leaving U.S.: w 17.Transporter Acknowledgment of Receipt ui Maledais Transpo r 1 Printed/Typed Name Sig;;ure Month Day, Year CL .s,ti aC,Is4 ..fi.+n � 7har" S .. QTranspo ter 2 Pnntdd yped a gn$ture Month Day Year 18.Discrepancy 18a,Discrepancy Indication Space ❑ Quantity Type Residue Partial Rejection ❑Full Rejection Manifest Reference Number: l 18b.Alternate Facility(or Generator) U.S.EPA ID Number J _ U ri Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year Z y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) G 1. 2. 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.3-05) Previous editions are obsolete.