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Please print or type.(Farm designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 1.Generator ID Number 2.Page UNIFORM HAZARpOUS g 1 of 3.Emergency Response Phone -77V Tracking Number WASTE MANIFEST w . TO G B F 5.Generator's Name and Mailing Address Generator's Site Address(if different than mating address) POMW 1`li?'n** Generators Phone; , 6.Transporter 1 Company Name U.S.EPA ID Number lT klt AIi VAI.Lt--',e 'vVlAalk(Al.,1J :. (�ROIXIVr Mx;{ 7.Transporter2 Company Name U.S.EPA ID Number ;xi-'LCI Lt'y 3lafiz3i I.lt'1i H,Int r<V.itJ4111111:lf 24 8.Designated Facility Name and Site Address U.S.EPA ID Number .�i al t;t;kd1l4't1(I iH1"1k�u1i kir 1v1c;i�Ai + h iUi�1A{.1P.1 t.t; t>Ft lg'E �:3 >[? ai£1 t W1fVLAI"M. t t Facility's Phone: ga 9b.U.S.DOT Description lincludirg Proper Shipping Name,Hazard Class,ID Number, 10,Containers 11.Total 12.Unit HM and Packing Group(if any)) 13.Waste Codes No. Type Quantity Wt,/Vol. 1. O ;•i. Nib MIR I&AZiG�,IS L 61UPAA]p_.,fY :, T i, PQ414 i y I,ilr�]1 tiflii3 Z 2. F d3,10 711:1 d J tiAt}h;e l k:, (3t Ft F,3+d.41 A'��1,6ARPAL 1 0N4 ,,f 3 . 3. I�"�.tA'If'i.iibb't7�,f +t'♦:^-1•l.I�+IPU3F3#�� `�'fJlt..IT,D��i..tilFiti +fli,:,r`M•C3�;s,rl I, �i i.'yf�li 1+► 8i.i't T1.1' T1a f AFt< 7i�k�i� 'T 41Ub"3 hl M a ri>arMtLyn. 111 i'1►t.Yi 'R 4. 14.Special Handling Instructions and Additional Information di 1 a�iE?'.'tiJ t i 11.d,N ' i� At1 E7 rti r i'i { i;3F5kt7 2f33{ 4A3 F 11 t tt(:t�+0(.F: E IiF.i -- i1r`� A81WIROF1,gT Ulf1l�F 1Wi�Af'.;"i("-N . �°y3c�fJ I:i3 C 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 labeledlplecarded,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. GeneratorslOfferors Print ped Name t Signature A Month Day Year "e J 16.International Shipments �n Z ❑Import to U.S. ❑Export from U.S. Port of entrylexit: Transporter signature(for exports only): Date leaving U.S.: LU 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printecirr ped Name Signature X. ` Month Day Year QTransporter 2 Printed/Typed Name Signature Month Day Year 16.Discrepancy 1 Be.Discrepancy Indication Space ❑ puantity ❑Typ e Residue ❑Partial Rejection ❑Full Rejection ❑ Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U Facility's Phone: LLI 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z 55 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LU 1 2. 3. Notice: State of California requires generator to photocopy and mail to 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in item 18a DISC with 30 days: Name Signature PA Box 400 EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. Sacramento,CA 95812-0400 GENERATOR'S INITIAL COPY