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!It <br /> Please prii.1-or type.(Form designed for use on elite(2-pitch)typewriter) Form Approved.OMB No.2050-0039 <br /> 714 �lfest Tracking Number <br /> UNIFORM HAZARDOUS 1.Generator ID Number �..Page I of 3,—Emergency Response Phone 4. <br /> -Y <br /> ? <br /> WASTE MANIFEST 0, tr JJK <br /> 5.Gap-rator.s-Name pnd Mailip -aGenerators Site Address(If different than mailing address) <br /> x 3P.-i-�. <br /> Generator's Phone: <br /> 6.Transporter 1 Company Name U.S.EPA I*D Number <br /> , -7 • -F <br /> iii 71 YA 'C'. <br /> 7,Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Dksi� t.V Facility*�par G"i U.S.EPA ID Number <br /> rf-.,N.--;.;r.:— I-K <br /> Facility's Phone: <br /> 9a. 9b.U.S.DOT Description Oncludinig Proper Shipping Name,Hazard Cass,ID Number, 10.Containers 11-Total 12.Unit- 13.Waste Codes <br /> HM and Packing Groul arty)�,? Quantity Wt.Nol <br /> No. Type <br /> T I- f1 7 <br /> 0 <br /> Z 2. <br /> LU <br /> 4. <br /> A.Special Handling Instructions and Additional Information <br /> 2 1 "s, LT. <br /> V <br /> N <br /> Z., <br /> 15, GENERATOR'SIOPFEROR'SCERIIFICATION:I hereby declare that the contents of this consignment are fully and accurately cesc(ibed above by the proper shipping name,and are classified,packaged, <br /> marked and labeledi/placarded,and are in all respects In proper condition for transport according to applicable international and national governmental regulations.!f export shipment and I am the Primary <br /> Exporter.I certify that the contents of thispnsignmRrit conform to the terms of the attached EPAAcknovAedgment of Consent. <br /> _45,:,10..0010" atump !WO-,;tbn fatoen4tAied,(p,4 -E.262.27ta)jif I am a large quantity generator)or(b)(If I am a small gyantlfy ge31e7atcr):s true. <br /> GeneratqaWQffer&s PrintpOTypo.-Narne. Signature Month Day Year <br /> Z, <br /> 41 <br /> -1 16,International Shipments' <br /> F. 7 import to U.S. 0 Export frorn U.S. Pon of entry/wdt <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> 17.TransporterAcknowledgment of Receipt of Materials <br /> LU Transp4,gger I PrintadfTypad Name, Signature Month Day Year <br /> gi <br /> Zco <br /> Transporter 2 Printed/typed Name Signature VT Month Day Year <br /> 15 <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity El Type ❑Residue ❑Partial Rei.aon ❑Full R.j.,tlo, <br /> Manifest Reerance Number. <br /> 18b.Alternate Facility(or Generator) US.-EPA ID Number <br /> L- FaclMly's Phone: <br /> 0 <br /> Lu 18c.Signature of Alternate Facility(or Generato-) Month Day Year <br /> 0 <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous caste treatment,disposal,and recycling systems) <br /> 2. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the man fast except as noted in Item 18a <br /> PrilltbdfTyped Name Signature iMonth Day Year <br /> -A Z. <br /> oo? -k I <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED F-ALCIUTY 10 GENERATOR STATE(IF REQUIRED) <br />