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Form Approved.OMB No.2050.0039 Tease print or type.(Form designed for use on elite(12-pitch)typewriter.) 4.Manifest Tracking Number UNIFORM HAZARDOUS 1 G eras r lD Number II f i , i 2.Page 1 of 3 Emergency Response Phane 9 WASTE MANIFEST , I [ C 1 `- I(- 'T 1- �I I 0 0 0 3 5 8 7 H 6 F L E 5 neratars re s �- (if different than mailing address Name and Mailing Add } Generators Site Address } �tt�: l n��cx kjrt� 1 t.a�_�> i z�r�� a��t . i i-1r('� [� fTri(!(1 �._ Gen ra e. 6.Transporter 1 Company ame U.S.EPA ID Number 7.Transporter 2 Company Name U 5-EPA ID Number 6.�g signaled Facility Name apd Site Address, U.S-EPA ID Number [.�I'Cco !4 Ci 1 t1X)r-, ]� rn, ret^iC/a i`] C"- Facl'chJs Pttbrfe a 0� !4 i— 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(it any)) No. Type Quantity Wt Nol. unj CA Eta U.1 2 C' Llrh ns {lZi�lCli �C� 1�.:,�if j�i�f.=Cat11C 1 t , � �1 ,P�} 14.Special Handling Instructions and Additions Information 4- 1, �('�I?Y--a:�5 LA a 1 .1 X 5 1�A):_)—i 1)( 15. GENERATOR'S10FFEROR'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 laheledfplacarded,and are in all respects in proper condition for transport according to applicable intemationaf and national gavemmental regulations.If export shipment and t 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. GeneratoesfOffery s Printe yp Nameigna u Monthy Year C1 i1�A) ) L ��all � !1 � -a 116.International Shipments F- ❑Import to U.S. ❑Export from U.S. Port of enlrylexit: z Transporter signature for exports ool : Date leaving U.S.: eu 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Prinledlr Namegnat"re Monthay ear Q Transporter 2 Pdntedrfyped Name 4 ign re Month ay Year 16.Discrepancy 1 ea.Discrepancy Indication Space Quantity EITYP, El Residue � � P��+WC Manifest Reference Number: -r-S b F 18b.Alternate Facility(or Generator) o -Facilitys Phone: i !L ')^ ISC.Signature of Alternate Facility,far Generator} 7�j�L (LZ `v�+ +� Year z :sbfras, N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) W 1, t Ito ._ 20.Designated facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a' PrintedfTyped Name Slgnalure Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED)