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Form Approved.OMB No.2050-0039 Please print or type.(Form designed for use on elite(12-pitch)typewriter.) UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WAST E MANIFEST �`) 3 ` -a �� 0`14206352 �� 5.Gen.rators Name and Mailing Address a^ Generator s Site Address(if different than mailing address) Generator's Phone: _ U.S.EPA ID Number 6.Transporter 1 Company Name y� y§ 7" a F v „ rod i..i.%SC'r.7a,YsJ t 7.Transporter 2 Company Name 1 U U.S.EPA ID Number 8.Designated Facility Name and Site Address J U.S.EPA ID Number C�Y&4 R'� 141=Aii-rii GNVIR ncDf10T11AC�IT tom,k�fi l@ irk 1530 W. 11"M '.-LONG ^K 13 f~� D012-�L-ig01`''t Facility's Phone: 432-644 9a 9b.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.Nol. o Fill M 1263,WASTE PANT F L.A I ED MANS. . 3s ' a.Firs Z 2. W _ t, 3. 4. 14.Special Handling Instructions and Additional Information 96.1 --USE APPROPRIATE - . ERG#128 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 EPAAcknowiedgment 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/Offerors Printedfryped Name Signature Month Day Year _J 16.International Shipments F_ ❑Import to U.S. ExP❑ ort from U.S. Port of entry/exit: Z Transporter signature(for exports only): Date leaving U.S.: 17.Transporter Acknowledgment of Receipt of Materials W Month Day Year Transporter 1 Primed/Typed Name Signature O CL E Z Transporter 2 PrintedfTyped Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U I Facility's Phone: Month Day Year LU 18c.Signature of Alternate Facility(or Generator) Q Z Fn19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 1 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Month Day Year Printed/Typed Name Signature EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL C4:IPY