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2011-Feb-24 02:13 PM DSW AG 209-339-8867 `i3 I Please print or type.(Form designed for use on elite(4-pitch) ewritsr.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1. enenstor ID Number) 2.Page 1 of 3. mergency Response Phone C MARW 1005745952 nber WASTE MANIFEST S.penetatoes Name and Malling address Oenarators lot Address 0 different than milling address) Generators Phone: .S.EPA ID Number 6.Transposer 1 Company Name 7.Transporter 2 Company Name U.S.EPA umber 8.oesignand Fedllty,Name end SRO Addr$3 U.9.EPA ID Number V Feclll s Phone: 9b.U.S,DOT Description(including Proper 6h Name,Heard Claus,IU Number, 10,Gontairlm 11,Total 12.Unit 13.waste Codes i HM and P&*Wng Group(If any)) No, a Quantity WtJVo1. Irl , ._ J..l - 1 r 4 1 4. 14.SpodW Handling instructons and Additional lrkrmaWA •.af'r_��•.t.rr.. 15. GENERAT01t'SIOFFEROR'S CERTIFICATION: I(Araby dodare that the coolants of this consignment era fully and accurately dosonbed above by the Mer stopping name,otb ars ciaselfled,peduged. lI marked and labeledlplacarded,and are In all reaps In proper conditlon for transport according to applicable Intsmagonal end national govemmentat regulations.It oxpart shlpment and I am the Pdmery Exporter,I cer*that the contents of"a consign¢¢rd mntonn to the terms of the attached EPAAcknowledgment of consent I certify that the waste minlmdalion statement identified In 40 CFR 262.27(a)(if 1 am a large quantity generebr)or(b)(If I aura snag Quantity generator)Is true• natur>t onth Day Year pana(atoewfferors PrintedlTypad Name Sigr 1 –_:f Te—1nitmalloraistlipments ❑Import to U g• C]F prort from U.B. Poi otmh6ylaxlt'' E Date leaving U.S.: i fa Transporter signature(for exports only) 1 17,TrinsporterAcmaNedgmentof Racelpt of Matedale Mon My ear nsponar ntadlfiyp ame Signature �. ,. p� randp6rter, n edflyp em Signature loath Day Year F 16.Dlacrapancy 18a.Discrepancy indication Space OuenUty a ❑ ❑Residue ❑Partial Ra)ecdon Full Ralecdan ❑ I Type Manifest farona N n U.S.EPA ID Number I lob.Alternate Facility(of Generator) 1 Facility's Phone: onth Day Year rte, 160.Signature of Ailemato Fa ly(or Generator) 18.Hazardous Waste Repos Management Method Codes(i,e.,codes for hazardous waste treatment,disposal,and redyaing aysums) 4. 1. 2 T. 20,Designated Facility timer or Operetor CenlfiCBdon t receipt of hazardous metadslo coveted by the manifest except ea nated In Item 16a cryyl ay Year nt ame Signature l GENERATOR'S INITIAL COPY HPA Form 8700.22(Rev.3.03) Previous editions are obsolete.