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Please print or type.(Form designed for use on elite(12-pitch),,,,.writer.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS �.� � w� �� , 1.Generator ID Numb)r 2.Page 1 of 3.Emergency Response Phone ManifestTracking.Number WASTE MANIFEST t" r,,t-, a!; J J K 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) �(.�f'`f."r r„ Y�ft'✓''��i'{�'r 1..Vd,F�:t„1�Lf Generators 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 la;>�t,fr+.il,�+ii Y vCrtl'ltlii i6w; r5lI)WUfH tkrYLE A4114iik 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)) No. Type Quantity Wt.Nol. 1. Z 2. L "--,E, VE.D- 3. APR 4. i,\!V f,0N ENT `.. PT INA I-NT 14.Special Handling Instructions and Additional Infom ation c M �dt;�til�f;Y tt.N�ilACt Urfl. l► .�: 'J. �Xt4�'+4-`9:3 10r W!'k...�f t''1`lf4ttl.L {,�t ita��, " I KilfilLt N 904 �KUnb-01(liLY;ssal.rt: r A ?Ttl tplryff '�+d!!)-�M �'fR�t: A4►r 'Sf F!iArc p;.xssrr+F.F! tjvtii '.'4t°ft r-r:u?1 r`PA y 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I 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 reslects 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 consig ment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement id ntified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generators/Offerors Pdnted(Typed Name Signature Month Day Year 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.: W 17.Transporter Acknowledgment of Receipt of Material Transporter 1 Printed/Typed NameSignature Month Day Year p fCL ZZ Transporter 2 Printed/Typed Name Signature Month Day Year W H 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑ ❑Full Rejection yp El Partial Rejection I Manifest Reference Number: 181b.Alternate Facility(or Generator) U.S.EPA ID Number J U Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) C 1. 2. 3. 4. 20.Designated Facility Owner or Operator:Certificaticri 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 am obsolete. GENERATOR'S INITIAL COPY