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F Please print or type,(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4,Manil st T acAing Numborr� , WASTE MANIFEST �� ' ('� ,�� O 1 .� 9 0 4 2 JJ K 5.Generators s Name and Mailing TIres, i; L` r �� " �' Generator's Site Address(If different an mailing address) f 6�4 Generator's Phone: 6.Transporter i Company Namer y t,hl ai'i i ,+E,i f i l ;iE$==7 f 1,i4, U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address 4 ii'?tlpj,'A�; lT:kf. U.S.EPA ID Number r?fi R0 ' ._.- . '.'.fizRfTT'r t":s• rr'rt;r7•t Facility's Phone: 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 t l,j.! Z W 3. t1l -- -4— Al Llr'Al a' DEFARTRUEN1 i 14.Special Handling Instructions and Additional Information ` f .;��nt.f=�;- r�,tar Tn 3rlr� =�,rin t f��'�{�t�•�� r 1= � �. ,�,.. d,..._ R C'N1;Ti? !Tnp p a f;,il r Ff f;llsrtr 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,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)(HI am a small quantity generator)is true. Generaloes/Offerces Printed/Typed Name Sig I re Month Day Year -� 16.International Shipments F- ❑Import to U.S. ❑Export from U.S. Port of entry/exit: 'Transporter signature(for exports only): Date leaving U.S.: 17.TransporterAcknowledgment of Receipt of Material—s-, Transporter 1 Printed/Typed Name r Signature r'� ,r Monte Day_ Year Z Transporter 2 Printed/Typed Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b,Alternate Faclllly(or Generator) U.S.EPA ID Number V Facility's Phone: 18c.Signature ofAltemate Facility(or Generator) Month Day Year 4 Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) W 1 2. 3. 4• o ' �11 /.lI 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted In Item 18a nn to Name 7 Signature / Month Day Year �� EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY'S COPY