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Please print or type.(Form designed for use on elite(12-pito.�.�ppewnter.) • Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS i.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.ManifestTraccking Nurn rr (� WASTE MANIFEST 100727 7 J P U JJ K 5.Generator's Name and Mailing Address Generator's Site Address(d different than mailing address) ..-_crp,_ .i. Generators Phone:" /'-r!I 6.Transporter 1 Company Name U.S.EPA 10 Number -G i'i l:'1t'-ihi idlA4Eh1T-1. _ , 7.Transporter 2 Company Name U.S.EPA ID Number S.Designated Facility Name and Site Address �::�..;,r-:.t .,: .:,i.. .1 ,..,..;�-. 7 U.S.EPA ID Number Facility's Phone'. 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) No. Type Quantity Wi 13.Waste Codes O z 2. W 3. 4. 14.Special Handling Instructions and Additional Information ,411f PNCA-i is .Y t. C.mi,'�. .. .. in0i( lt . ,r0 irl 15. GENERATOR'S/OFFEROR'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,)cedify that the contents of this consignment conform to the tonna of the attached EPA Acerimiedgment of Consent. I certify that the waste minimiration statement identified in 40 CFR 262.27(a)(if I am a targe quantity generator)or(b)(MI am a small quantity generator)Is true. Generator'sfOfferors Printed/Typed Name Signature Month Day Year 16.International Shipments _ ❑Import to U.S. ❑Ezport from U.S. Port of entry/exit: Transporter signature(for exports only): Date leaving U.S.: W 17.TransporterAcknowledgment of Receipt of Materials C Transporter 1 Printed/Typed Name O Signature Month Day Year a td, � Transporter 2 PnntedRyped Name Signature Month Day Year r } 18.Discrepancy 18a.Discrepancy Indication Space El Quantity ❑Type ❑Residue ❑Partial Rejection ❑Fuli Rejection Manifest Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U Facility's Phone: 18c.Signature ofAltemate Facility(or Generator) Month Day Year 2 H19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) C 1 2. 3. 4. 1 20.Designated Facility Owner or Operator.Codification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Pnnted/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) PTIioue editions are obsolete. GENERATOR'S INITIAL COPY