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Please print or type.(Form designed for use on elite(92 pitch)typewriter.) Form Approved,OMB No.2050-0039 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.M614051024- ifest Tracking Number �j UNIFORM HAZARDOUS �1 �,0 2�#. r�r�K WASTE MANIFEST 5.Generator's Name and Mailing Address Generator s Site Address(if diBerent Ihan mailing address) i Generator's Phone: U.S.EPA ID Number 6.Transporter 1 Company Name U.S.EPA ID Number 7,Transporter Company Name U.S.EPA ID Number j 8.Designated Facility Name and Site Address i Facility's Phone: A 9e gb.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.Nal. l O w 2 �\ q . LLI i 3. P 4. IIJ 14.Special Handling Insiniceons and Additional Information � a ,"r'�': ,1 •'�."f!r_S., I(aM�r�l")�8; �f''°,r "": accurate) described above by the proper shipping name,and are classified,packaged, consignment are full and y 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of according rdingtY 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 EPAAcknowledgmenl of Consent. I certify that the waste minimization statement identified In 40 CFR 262.27(a)I I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Month Day Year GeneraloeslOfferoes PrintedlTyped Name Signature J 16.International Shipments Import to U.S. ❑Export from U.S. Port of entrylexit: E z Date leaving U.S.: Transporter signature(for exports only): K 17.Transporter Acknowledgment of Receipt of Materials gDa W Signature Transporter 1 PrintedlTyped Name j O , CL Signature ZTransporter 2 Prii tedlTyped Name 18Discrepancy18a.Discrepancy Indication Space Quantity ❑Type Residue ❑Partial Rejection !I , Manifest Reference Number: U.S.EPA ID Number : 18b.Alternate Facility(or Generator) It Q Month_ Day Year LL- Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Q r Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling sys ems 4 w 1 2. 3. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest as noted in Item 18a Month Day Year Printed(fyped Name 6 GENERATOR'S IIVIl-IAl.COPY EPA Form 8700-22(Rev.3-05) Previous editions are obsolete.