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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 Phone 4.Manifest Tracking Number WASTE MANIFEST O O J U 0.3 5 JJ K 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) Generators Phone: 6.Transporter 1 Company Name U.S.EPA ID Number 7. ransporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number ;vii:. ;" .. .- ?,�1,''•i';.-,:,?;,,} Psi, ,.. = .. Facility's Phone: ya 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. O �a ,t t ,, I r z2. w c� 3. 14.Special Handling Instructions and Additional Inform tion 15. GENERATOR'S/OFFERZCERTIFTION: 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/placall 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 theonsignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste ' ent 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. eratoes/0bwe- nntedrryped Name Signature � �. Month Day Year .-1 16.International Shipments f H p 1:1 Import to Ps". ❑Export from U.S. Port of entry/exit: Z Transporter signature(for exports only): Date leaving U.S.: L= 17.Transporter Acknowledgment of Receipt of Materials Tr rt er 1 Printed/Typed Name Signaturi Month Day Year a q 1C)y z ansporter 2 Prin d/Typed Name Signature / Month Day Year Q t•- 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity Type ❑Full Reje ❑ El Partial Rejection Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U LL Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year a Z 55 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 1. 2. 3. 4. Ll20.Designated_.Fpcility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrintedlT Namenatur n Jay Ye' k - f-MIL u r4-- ,62]�A-Z- 1J1A11k 1G)"i EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. p ONATED FACILITY TO DESTINATION STATE(IF REQUIRED)