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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.Emergenc�Response Phone 4.Manliest Tracking Number] WASTE MANIFEST 1 354 JJ K 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) I.l+►�`d1.S`t�a3'3t`' 4?�'�'.:>8 11 la:.; r,Y r r� » ..i... 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 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. LU 2. UJ (9 3. 4. 14.Special Handling Instruct p g ions and Additional Information Ioi t ,r sIl i I1 tiavk# ', a '.1fi # '3"r tt $:R.: fl.-`} Rr A9101W6 rPF'P0PRI 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 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. G�neratoeslOflerors PrintedlTyped Name Signature Mq�th Day Y ar i J, -J 16.International Shipments [= ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day Year 0 tL Z Transporter 2 Print rryped Name Signature Month Day Year H 18,Discrepancy 18a,Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 7 18b.Alternate Facility(or Generator) U.S.EPA ID Number J_ V LL Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z H19.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 1 Be rioted yped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY