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Ho 0 0ae" o a C Sit 4'F 4' F m CT a Q,m m 4 o A Form Approved.4M13 No.2050-0039 c° aQ m e m = +r `b ,ed for use on elite(12 pitch)typewriter.) m'1� `+°� �S'1,Venerator ID Number 2.Page 1 of 3.Emergency Response Phone 4,Manliest Trac9sing Number �. �Q o .,FEST 0 U.) � SLE mn s Name and Mailing A.ddrsss Generators Site Address(f diBerent than mang address) Q C 3rGenerators Phone: U.S.EPA ID Number 6. ransporier 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA 10 Number B.Designated Facility Name and Site Address Facility's Phone: 9b.U.S.DOT Description(including Proper Shipping Name.Hazard Class,l0 Number, 10.Containers 11.Total 12.Unit 13 Waste Codes HM and Packing Group(if any)) No. Type Quantity WLN01. 1. OC O Z 2 Uj t7 3. l 14.Special Handfurig instructions and Additional Information 15, GENERATOR'SlOFFEROR'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 Iabeledlplacarded,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. --Month ay ear I onerato sl fferors Phinted/Typed Painted/TypedName igna re j —i 16 International Shipments ❑Import to U.S. Export from U.S. Port of entrylexit: -- z Date leavingU.S.: Transporter si nature(for ex aRs on! : I w 17.Transporter Acknowledgment of Receipt of Materials ontt ay ear igna ure Transporter 1 Printed Typed Name I 1 QI ry 0nth ay Year QTransporter 2 PrintedfTyped Name ignature 18.Discrepancy I Ba.Discrepancy Indication Spare Quantity 0 Type Residue Partial Rejection ❑Full Rejection Manifest Reference Number: U.S.EPA ID Number I Bb.Alternate Facility(or Generator) J v u Facilit's Phone: Month, Day Yea W 18c.Signature of Allemate Facility(or Generator) a 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 4 W1 2. 3 20.Designated Facility Dwner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item IBS Month Day Yea PrintedfTyped Name Signature GENERATOR'S INITIAL CC EPA Form 8700-22(Rev.3-05) Previous editions are obsolete.