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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 Generator ID Number 2.Page 1 of 3,Emergency 4. rn est-T rgbC 1.G !ncy�Res 2"Q UNIFORM HAZARDOUS 2 39 SKS WASTE MANIFEST 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) i 'J Generators Phone: U.S.EPA ID Number 6.Tranepodr,tGomparly Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.,,,EPAP Number a.Designated Facility Name and Site Address t:.' -A Facility's Phone: ers- it.Total 12.Unit 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, Quantity Wt.Nol. 13.Waste Codes HM and Packing Group(if any)) No. Type �7..., V . "i :' , I I. ...'-- I 4 [. r- (7 R 4 t1 Z IF 0 Z 2. 3. 4. Q 14.Special Handling instructions and Additional Information 1 Y F k�� -4 "J b, rL z. I N 15. GENERATOR'SIOFFEROWS 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, ort shipment and I am the Primary marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national III-overnmental regulall s.on If exp Exporter,I car*.that, the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I certify the.t 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. Month Day Year �GertqrslOfferor`s Printed[Typed Name7gn tore k -J 16.International Shipmentsimport to U.S. El Export from U.S. ..,P'o-rt of ntrylexit: Ej Transporter signature(for exports only): Date leaving U.S.: 17.Transporter Acknowledgment of Receipt of Materials S. Month Day Year Trans fped NP�e lign _e p rt r 1 Printed[TI eo IS v O CL ./(-' -V Month Day Year ca Signature Z Trani-porter 2 Printed/Typed Name I18.Discrepancy 18a.61sorepmcyInd6tionSpce Quantity ❑Type ❑Residue FiPartial Rejection El Full Rejection — Manifest Reference Number: U.S.EPA ID Number 18b.Alternate Facility(or Generator) uQ Facility's Phone: Month Day Year Generator) UJ 18c.Signature of Alternate Facility(or G Z 1 Pnnta�ffj n I P Y—Pn FTMnipo 'S2 79.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) W — G1 2. 3. 4. 20.Desigipated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a W Signature Month Day Year PrIn 'pl,d Name DESIGNATED FACILITY TO GENERATOR EPA Form 8700-22(Rev.3-051 Previous editions are obsolete.