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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050.0039 UNIFORM HA7ARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.M¢ if��t cog jVupber . 2;5 u i.��r° , FL E WASTE MANIFEST t rYl.: T,".?�'ct ),M-795, ' ti�TM 1 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) Generators Phone?'a i-OW-2 C-tr 6 Transporter 1 mpany Nae _ U.S.EPA ID Number ("APMWOF-lill 7.Transporter 2 Company Name U.S.EPA ID Number 8 Designated Facility Name and Site Address U.S.EPA ID Number J1:3 F..:s'�1ih am > ��it�f3 vCd(��S?aJ?rr�3d r . r 7 L)a Facility's Phone: ga. 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)) fs G No, Type Quantity WI.Nol. f,►Et'V's 4:'iii ..'l.zi'77I CRS.i4�,:j��i'�,1'4t',�,..,1:1,rf�3:r 0 j r./r t�f Z 2. LU C7 3. 4. 14.Special Handling Instructions and Additional Information Ft*';>.:A 15, GENERATOR'SIOFFEROWS CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately descrbed above by the proper shipping name,and are classified,packaged, marked and labeled/placarded,and are in all respects in proper ccndition 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 f am a small quantity generator)is true. GeneratorslOfferors Printedityped Name ....... Signature Month Ta—y —Ve—ar— �J 16.Intemational Shipments ❑Import to U.S. ❑Export from U.S. Port of enlrylexit: z Transporter signature for exports only); Date leaving U.S.: LO' 17.Transporter Acknowledgment of Receipt of Materials Transporter i Printedfiyped Name 1t , i gnature ontth Day ear 4 •J�J'ii y�l7 f . c)�"'`r/,� L1 I ,.i' f.r` I /- I ; �}fl �� QTransporter Printed/Typed Name `` Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residuej j ❑Partial Rejection Full Rejection Manifest Reference Number: 18b.Aitemate Facility(or Generator) U.S.EPA ID Number J_ C7 Facility's Phone: w 18c.Signature of Aitemate Facility(or Generator) Month Day Year a Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) G 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 Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3.05) Previous editions are obsolete. GENERATOR'S INMAL COPY