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eeP/ fo !� C o i30X 1,16110,Scicl- '---'—1 ,,.1" 'h jet C& y1 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 C,14 2 p 0 CC) �9 7� �cam/ /a 4zy-93•Gb 010 8 2 8 2 61 JJ K 5.Generator's Name and Malin Address Generator's Site Address(if different than mailing address) I4e.1 s 1VZ 14SA '2q)CFos, 46�-L r>02.4 rev Si dEdn/ C.4 95Zv� Generator's Phone:(_70,q 3 Z— 6.Transporter 1 Company Name / U.S.EPA ID Number )'—e$!7 C/j!/1 S C)i7rs�v�s, .S-�✓" i Ces ±�D VY2 Ylj L' C Z 7.Transporter 2 Company Name U.S EPA ID Number B.Designated Facility Name and Site Address q� 'J / U.S.EPA ID Number G,GrI�� /I�y�^'O>'7/�?L/!�2/-7'r�fx`�'.'�^z-��c9�'N...t�ri.�CA�h .Zp 95 r/'ft.✓/eir oil D2�tcz E�Sf Facility's Phone: 7(cc) cid 6 9$3 3.3' 9a_ 9b.U.S.DOT Description(including Proper Shipping Name.Hazard Class,ID Number, 10.Containers 1;.Total 1) Un t HM and Packing Group(if any)) No. Type Quantity tis.Waste Codes I. ;"'PJcI o 5>/ �� SS% �C�,j 1�c�// � LU 2. UA/Z C- f .vrCG / � 1 �v c7c: 3. 4. 14.Special Handling Instructions and Additional I omtatiop Ct i6l , R-G-A/oto /e � /02 79.3-(370 ll-!"Z— i 15. GENERATOWSIOFFEROR'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 FPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(d 1 am a large quantity generator)or(b)(if I am a small quantity generator)is true. GeneratorslOtferoes Printed/Typed Nqme signature Month Day Year -J 16.International Shipments 1=- ❑import to U.S. ❑Ex,rt from U.S. of trywi, z Transporter signature(for exports only): Date aving U .. W 17.Transporter Acknowledgment of Receipt of Materials 0 Transporter 1 Plinf Signature Month Day Year IL QTransporter 2 PrintedlTyped Name Signatur Month Day Year I- I- 18. 16.Discrepancy laa.Discrepancy Indication Space ❑ Quantity ❑ ❑ ❑ Type Residue Partial Rejection ❑Full Rejection Manifest Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA ID Number J_ +J LL Facility's Phone: W 18c Signature of Alternate Facility(or Generator) '4o I'r Dav Year a Z y19.Hazardous Waste Report Management Method Codes p.e.,codes for hazardous waste treatment,disposal,and recycling systems) Q 1' 2 3• 4. 20.Desgnated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature blon h Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED F-ACILITYTO DESTINATION STATE (IF REQUIRED)