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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.Page 1 V 3.Em7Response Phone 4.Manifest Tracking Number WASTE MANIFEST 0042 719, ELE 5.Generator's Name and Mailing Address Generator's She Address(if different address) .3 Generators Phone: U.S.EPA ID Number 6.Transporter Company Vame 7.Transporter 2 Company Name U.S.EPA ID Number 8,Designated Facility Name and Site Address iNumber 1T. C Facility's Phone: 9a. 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity WtNol. 0 Z 2. LLJ CJ 3. e. 4. 14,Special Handling Instructions and Additional Information 4 S 1 ri -3 8 L N 15, GENERATOR'SIOFFEROR'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)(if I am a small quantity generator)is true. -GeTr,—to1s0Offeror`s Pdntqdrryped NarZe Month L-< _-j 16.1riternational Shipments —nExp.rt from U.S. Port of entrylexit El Import to U.S. Z Transporter signature for exports only): Date leaving U.S.: 17'Transporter Acknowledgment of Receipt of Materials Month Day Year Tran Mr,I PrintecirTyped Name Sign 0 CL U) Signature Month Day Year TranglZfter2 Printedrryped Nam'd 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity El Type El Residue El Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number FacilitVs Phone: ca Month Day Year LL, 1 Bc.Signature of Alternate Facility(or Generator) Z as 0 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment disposal,and recycling systems) -13. 4. 20.Design6ted Facility Owner or Operator.,Certification of receipt of hazardous materials covered by the manifest except e§,noted In Item 18a Da Year Name Signaturey 77 EPA Form.87.00-22 R 2( ey..3,-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR