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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.Pegs 1 of 3.Ernergeney Response Phone 14,Manifest Tracking Number `A r WASTE MANIFEST ,,. ;5>;: •:f?.<- :.;: s 000197994 M I 5.Generatoes Name and Mailing Address Generator's Site Address(if different than railing address) Generators Phare: 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.FPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number FaaitysPhone: ga• 9b.U.S.DOT Descnpd m(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(t any)) No. Type Quantity Wt.Nol, O TDT- ��Uj 5' CD a�-?°- . .:ir4:�-' ;� 9- .._.� -;, .9'?�+yf, r3';i.Aw,=�:_rrat-� ;-� ! -�+•—� 4. 14.Special Handling Instnxtions and Ack itiad Intormation („ f. :1, 9'b ,.F t .•,�..r.:i:. •t c11' ''(i .. :t?: i 1. ..t-•-•:-i':-.z..a,..� ..._ �,.f 1..._ .. rw.k - :.�,•`-'^. -r•t•..,r�_.... .. " �sd a�:f"}t- ..t_v,..:,t.i.h:;",,..: �;_.._ �.... '-F."-^"^'i r !,S•.:i: tri ,'i,' :i .�i :Y •�.: ;a. 15. GENERATOR'SIDFFEROWS CERTIFICATION:1 hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,ard are classified,packaged, marked and labelediplacerded,and are in ail respects in proper condition for transport according to applicable International and nates govemmental regulations.If export shipment and I am the Primary Exporter,I car*that the oD ntents of this consignment oonbm to the terms of the attached EPAAeknavddgment of Consent. I certify that the waste minimization statement entified In 40 CFR 26227(a)(If I am a large quantity generator)or(b)(if I am a small quantity generator)is true. GeneratorsVerces PrintedfTyped Name Signature Manch Day Year a 16.intermnal Shipments p � ❑Import to U.S, ❑Export from U.S. Port oferrbyledt: i x Transporter signature(for exports only): Date having U.S.: 17.TransporterAcknovdedgment of Receipt of Materials Tminsporter1 PrintediTypeddame Signature Month Day ({Year CL QTransporter 2 Pri yped fine Signature Month Day Year N 1s.Discrepancy 189.Discrepancy Indication Space F� Q ty ❑Type ❑Residue ❑Partial Rejection I_J Full Rejemon Manifest Reference Number. 18b.Alternate Fadfity,(or Generator) U.S.EPA ID Number J U Fealitys Phone: 180.signature of Alternate Facility(or Generator) Month Day Year 19.Hazardous Waste Report Management Method Codes(La.,codes for hazardous waste treabnent,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 18a PrintedfTypudNarrre Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY