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a- 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.Emerge Response Phone 14.Manifest Tracking Number WASTE MANIFEST / G / � / q — �— �J�p 001736221 JJ K 5. rator's Name and)9ailing Addres �' �L Genelomf s Site Address(if differ e t han marlin d ass) Gln Gene o on 6.Tr nsporter 1 Co any e U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number ^`fgfated F 'Ii Na an ite�Address '/� U.S.EPA ID Number Facility's P one: 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./Vol.1. Z 2. W U' 3. 4. 14A ct HSOng Instructions and Add/tonalriforrm-ation `/t' r?ws�/1—A-�i , 1Z, /i�f//f !?f'?C1frt/"G'/ .1.. /:-(? 7 F&6,' 6 .�'�1� 0 1 riV"7"!C-(�' F% Lent.// : �'� � !_ s�'t1 15. GENERATOR'SIOFFEROR'SCERTIFICATION-1 hereby declare that the contents of this consignment are fully aridkcurately 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)(if I am a small quantity generator)is true. Generator's/Offeror's PrntedfTyped Name Sig r n Month Day Year 109110107 -J 16.International Shipments (- ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Z Transporter signature(for exports only): Date leaving U.S.: Of 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Pdntedffyped Name Signature Mo Day Year CL y y .z� �r Z Transporter 2 Printed/Typed Name Signature Month Day Year H 18.Discrepancy 18a,Discrepancy Indication Space ❑ Quantityyp ❑T e ❑Residue ❑Partial Rejection Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J v Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z 0 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 1. ) 2. T- 20. Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a P ntedlTyped Name ^T Signature Month Day - Year �- Q EPA Form 8700-22(Rev.3-05) P vious editi ns are bbsolete. ' DESIGNAtElPi FACILITY TO GENERATOR STATE (IF REQUIRED)