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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved,OMB No.2040-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of6Ernergency Response Pbone 4.Manliest Tracking Number WASTE MANIFEST Ck� 2 � �1 -0+�3_. 005231779 JJ K 5.Generators Name and Mading Add re55 Generators Site Addre (if different than mailing address) $ � (A� LA+� � � D ply. bt'�rxl t `CJi -►-'4P 313 - c12.� Gene atni s Phone: 6.Transporter 1 Company Name U.S.EPA ID Number �Q� �N>�I MIM kill kOD t3jUk 7.TransporK2 Company Name U.S.EPA ID Number C 8,Designated Facility Name and Site Address t4 1 U.S.EPA 10 Number Facgil N Phone: C!" ga_ 9b.U.S.DOT Description(inching Proper Shipping Name,Hazard Class,ID Number, 10,Containers 1f.Total 12.Unit 13.Waste Codes HM and Packing Grp td any)) No. Type 1 Quantity WI-11M. X 1. 000- C Ar "W-4 ax 40 01 V h 950 0 a Uj z 2. w L:L 14.$p c Hardl�in`Instru�as dAAddditional Information �+hE � L f I� pss'�j 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 dassided,packaged, marked and IabeferUplacarded,and are in all respects in proper conditbn for transport according to applicable intematienatand national governmental regulations.If export shipment and I am the Primary i Fxporter,I certify that the contents of this consignment conform to the terms of the attached EPAAckrtowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if 1 am a large quantity generator)or(b)(11t a all quan orator)is true. Gen atorsl r nted[Typed Na Signature - Month Day year % 416.I tional Shipments ❑Import to U.S. ❑Export from U.S. Partj- r19' exit: Transporter signature(for exports only): DafeU.S.: LW 17.Transporter Acknowledgment of Receipt of Materials Transporter I PrintedfTyped Name Signature Month Day Year a r9. )f Q LA QTransporter 2 PrintedRyped Name svisture Month Day Year a 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejecban ❑Fug Rejection Manifest Reference Number: 18b.Alternate Facility tor Garmrator) U.S.EPA ID Number J ty lQi Faafdy's Phone: _ - Month Day Year Lk I Be.Signature of Alternate Faclydy for Generator) z N19.Hazardous Waste Report Management Method Codes(i.e.,lodes for hazardous waste Sreatment,disposal,and recycling systems) LU 1. 2. 3. 4. 20 Designated Facility Owner or Operator Cedification of receipt of hazardous materials covered by the manifest except as noted in Item IBe PrinteddTypod Name Signature fix i Day Y� E?A Form 8700-22(Rev,3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED)