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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.M ife(t T c ng u e WASTE MANIFEST U �Lc 5• v J �7 0 �A ��z . , u JJK 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) ICA u "F57- t r iC. k A y w 0757- 1 W C. w. 5 A t-h-f> t•y rJ cr A- 1AS CA tli - L-A-rIt-W o l' c_A. C 5"53>0 Generator's Phone: Tom- k- 6. 6.Transporter 1 Company Name U.S.EPA ID Number IJ L '�N sq 1 v, w&c.17-4 L 5 C-yt,4% C nt C. 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number rr1CC\mac-4 <3-,L k K C.. A `314 `` �(� G'�+j� L(�!'v 3'i zkt-1 5-6G Facility's Phone: ,Q 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. � 1.rvv��l�(�� ,APOcry>�,., q STS. �.•-r`�v:n a z 2. UJ 3. 4. 14.Special Handling Instructions and Additional Information r � U��fL [�5u►�i.�lr )�l.0;TC CTi\CC wo 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 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. Generator's/Offeror's Printed/Typed Name Signature Month Day Year .J 16.International ShipmentsEl � ❑Import to U.S. Export from U.S. Pod of entry/exit: Z Transporter signature(for exports only): Date leaving U.S.: rY 17.Transporter Acknowledgment of Receipt of Materials LU Transporter 1 Printed/Typed Name Signature Month Day Year O NMonth Da Year ZQ Transporter 2 Pdnted/Typed Name Signature y 18.Discrepancy 18a.Discrepancy Indication Space El Quanlity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: r 1Bb.Alternate Facility(or Generator) U.S.EPA ID Number J U LL Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z CD19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) O 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 Sionature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. Fr S .P �1T1-D 17ACII_ITY TO DESTIMAATION S7ATla 11IF lit-(3all F-P)