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/ ^^ � Please print or type.(Form designed for use on elite(12-p..-.,,typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1 1.Generator ID Number 2 Page I of 3.Emergency Response Phone 4.Manifest Tracking Number 0 5.Generator's Name and Mailing Address Generator's Site Address(If different than mailing address) 2WO E-1 DORADO ST 57'�JGKTON. GA Generators Phone: 6.Transporter 1 Company Name U.S.EPA ID Number Transporter 2 Company Name U.S.EPA ID Number Ln;te7d F--dr fy Name and Site Address U.S.EPA ID Number Hga. U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Contaii ers 11.Total 12.Unit M at id Packing Group(if any)) NO. Type Quantity Wt.Nol. 13,Waste Codes 0. X MA CD ' 14.Special Handling Instructions and Addifional Information A- 74M7 E RG B; 74967 ERG C 24958 ERG -9b� 1 5. GENERATOR;SIOIFFEROR'S CERTIFICATION: I hereby declare that the, s ait this consignment are fully and accurately described above by the proper shipping nime,and arAWsified,packaged, inarked and labeled/placarded,and are in all respeA in proper condition wr u ansport 3,*cording to applicable international and national governmental regulations.IfexpDrI shipment and lamthePhmary F,xporter,I certify that the contents of this consigntnnt conform to the terms of thu�,tiaclikd EPA Acknowledgment of Consent. ste minimization statement identified in 40 CFR 262 21T(a)jif I am a large quantily generator)or(b)(if I F, i a small quantity generator)is true. �cartify that the W�, Gene,atoes/Offeroes Printedffyped Name Signature nth Day Year -J 16.Intmmational Shipr�ents 1— 11 Import to U.S. Export from U.S:- Port of entry/exit 7- Tr�,nsportar signatufa(for exports only): Date leaving U.S.: 9Z ?1.rransporter Acknuwledgment of Receipt of Materials UJI Month Day 76—ar 2T 5��-,Insporter 2 Printed/Typed Name Signature Moolh Day Year DiscrOnancy � —L-- 18. Indication Space Quantity Tyne 0 Residue 0 Partial Rejector, Full R.Jecti.n Manifest Reference Number Job.Aten iate Facility(or Generator) U.S.EPA ID Number Al Facility's Phone: a 1 Bc.Signature of Alternate Facility(or Generator) Month Day Year ro 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 20.Designated Facility Owner or Operator:Cerfifica on of receipt of hazardo aterials covered by the anifest except as noted in Item I Ba Printed/Typed Name if us m m Signature --M—onth Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY --