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, :, 4 �.,, , .... �'.t�. fox �Ci2 S�CraFrt��ra, C, �+,'� 4 , . � •'i,};'tiid) 3=� f��z�rs* Please Drint or tvge. fForm designed for use on elite 02 Ditchl tvoewriter.) Fnrm Annrnvari ()MR Nn gnsn.onia 13 NT. MEN' UNIFORM HAZARDOUS 1. Generator ID Number. '' '' �' 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number ' `� r7 r) -1 t^ WASTE MANIFEST ,!� ._ 5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) Ui�fE; ;1 jr�fJG[s1.�i� e14 Generator's Phone: "' '— 1 N 0 V 04 Z 6. Transporter 1 Company Name U.S. EPA ID Number iNW*R�3�W� ,N��,.�,L ti CES ENVIRONM 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address U.S. EPA ID Number _. 0C. N- ' : rpt, C 94560 CkLii), 03137C. 8 Facility's Phone: 5J() -7 a6-44()0 9a. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13, Waste Codes Type HM and Packing Group (if any))No. Quantity Wt.Nol. 1. W 2 • 'T 'I�� I ��✓ IF.////SII'!/7 fJ'�s�V/�i.//�%frJ/l/.'�iC. �. / 1723 14Jpecial Handling Ins ons ,ajd Additional Information J . � Use peopiliate 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/Offeroes Printedfryped Name Signature Aa Month Day Year J ',moi —J I— 16. International Shipments ❑ Import to U.S. ` ❑ Export from U.S. Port of entry/exit: 1-114 Z Transporter signature (for exports only): Date leaving U.S.: W .17. Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Si n ur Month Day Year Aq QTranspofter 2 PrintedfTyped Name Signature Month Day Year I- 18. Discrepancy 18a. Discrepancy Indication Space ❑ quantity ❑ Type ❑Residue ❑Partial Rejection El Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number U Facility's Phone: w 18c. Signature of Alternate Facility (or Generator) Month Day Year H Q Z LD 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 0 1. /may/ 1 6 1 2. p{ /-Ii , � 3. fl�C I 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 Day Year EPA Form 8700-22 (Rev, 3-05) Previous editidns are obsolete. 13 NT. MEN'