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Please print or type. 1 . Generator ID Number Form Approved, OMB No. 2050-0039 FGeneratoes ZARDOUS 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number /� NIFEST 0 1 c �� l me and Mailing Address Generator's Site Address (if different than mailing address) E _ 10 AFJ Generator's 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 c• ��- . e 3 �' ' � �� aurp 1TV 8. 64 �iv`�P �� Facility's Phone: pB m o 9a. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Total 12. Unit HM and Packing Group (if any)) No. Type Quantity Wt.Nol. 13. Waste Codes 1 . ,.. t D11 7� _- m 2. UJ 3. 4. 14. Special Handling Instructions and Additional Information _ 15. GENERATOR'S/OFFEROR'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);(ifl)mAnmall ty generator s true. enerators/Offf 1 s Pnnted/Typ id Name a Signature f• ° . Mont Day Year f 1 �. 16. International Shipments F- ❑ Import to U.S. ❑ Export from U.S. Port OIF try/ Transporter signature (for exports only): Date leaving U.S.: W 17. Transporter Acknowledgment of Receipt of Materials LLJ Transporter 1 Printed/Typed NameSignature Mon D Year CL : r Transporter 2 Printed/Typed Name Signature Month Day Year 18. Discrepancy 18a, Discrepancy Indication Space ❑ Quantity ❑ Type YP El Residue El Partial Rejection ❑ Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number V - ILL Facility's Phone: 18c. Signature of Alternate Facility (or Generator) Month Day Year 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) ® 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 18a Pdnted/Typed Name Signature Month Day Year 1.PA Form 8700-22 (Rev. 12A7) Previous editions are obsolete. DE BIGHAT!K) R,=aCN j T Y TO EPA's G=NIA NIFES ' SYSTEM] I i - _