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i Please ghfl(:or p4.=(Form designed for use on elite(12-pitch,.ypewriter.)' Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST ; , ;.:' :„ -, l 'r - 85 JJ K 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Generator's Phone: 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number is].vll+. Facility's Phone: ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 3 Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 1. 6:i4 1 E `Fi Z ra f ('.1,1..111,1'1-; Poi's l•' +: ) o I. ti-•? �f l� }ii;; i ;s A!4;. r r ii-c_..__.r:F-11 H A,',FFr., -r•+'----- 4. 14.Special Handling Instructions and Additional Information 4171, 1 r,i :+ >� •___ r _ 1r-r' fll..tl',• P�€"vr fyyttEFiI@IIT @k'I(:h:j �tLfltRkltE:>q t c Mill ��jbi liffi il114`44il i1K,1i14t IN!4111,fill;Gi ; •AV, 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. 4certify 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 Printed/Typed Name ` ignature Month Day Year r —J 16.International Shipments F- ❑Import to U.S. ❑Export from U.S. Port of entry/exit: z Transporter signature(for exports only): Date leaving U.S.: w 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day bear i rn Z Transporter 2 Printed/Typed Name Signature Month Day Year H 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantit y El Type El Residue Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Genera or) U.S.EPA ID Number J_ V LL Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z y19.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 PrintedlTyped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY