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DTSC. 042"68. 0158 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.Emergency Response Phone4.Manifest Tracking Number WASTE MANIFEST C P,C. C O Z CJ as z - 1017117850 JJ K 5.Generator's Name and Mailing Address Generators Site Address(d different than mailing address) 5 w k FT 'MA NS1DOl +n ON 4a9-P0"rLON (S L5-v T t\0YLri 1-0" Q-o P r zZvro 5QX-5 H ' T4 t,r�Fa-e 11-0 1PA0eNq" R %s13 y3 Generators Phone: Ll - ZB 6.Transporter 1 Company Name U.S.EPA ID Number P O \ C-P" 0 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number C_'R-o S P-Tv \63a 5 r, LON (-N V->EAt4ll,, CJS %A,0qj13 Facility's Phone: -j- O 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 arty)) No. Type Quantity WL/Vol. 1- WON- P-c-V-P, INR-ZA9-!Dv05 --tA5FU, 50u0 3SZ l��e> co•y 7-i*w 1 N<T T C-O P P c iD��^,1z�s) 002- O v+n y,5- P W 2. N \��3 o\t5 r� e\ , 3 r P a\��r�� 400% Orn 5� C-733 l C) 3. 4. 14.Special Handling Instructions and Additional Information_y_ BAR papPtaHz p P P S p.0,k (pp `16 oz X ssgN orc,jw`5 � AF kotosZ3 9bZ'. 01 y. SS gF�ue t$\oo539t 5'D 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 classified,packaged, marked and labelediplacarded,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 cenfdy 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)(i1 I am a large quantity generator)or(b)(if I am a small quantity generator)is true. GeneratorsWerors PrintedrTyped Name Signature Month Day Year D/J l3EN o $,C. r►tit' ✓ 1��NdiP o7ti J 16.International Shipments F_ ❑Import to U.S. El Export from U.S. Port of entry/exit Transporter signature(for exports only): Date leaving U.S.: Of 17,Transporter Acknowledgment of Receipt of Materials Uj Transporter I PPrinted/Typed Name Signature Month Day Year a Gr/Avg f D /D I QTransporter 2 Printed/Typed Name Signa Month Day Year fY t- 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number. 181b.Altemate Facility(or Generator) U.S.EPA ID Number V Facilitys Picone: w 18c.Signature of Altemate Facility(or Generator) Month Day Year z 19.Hazardous Waste Re rt Management Method Codes(I.e.,codes for hazardous waste treatment,disposal,and recycling systems) G 1, (4-12. H(Z+ 3. 4. H1 20.Designated Facility Owner or Operator.Certification of receipt of hazy us materialscovered by the manifest except as noted in Item 18a PrintedlTyped Name Signature Month Da Year Z / EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) 12653.0870