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Please print or type.(Form designed for use on elite(12-pitch)typewriterForm Approved.OMB No.2050-0039.) I tTrackingNumber 1. enerator ID Number 12-Page I of I 3..;Emergency Response Phone. 0 Ink UNIFORM HAZARDOUS WASTE MANIFEST 3444894 SO 5.Generator's Name and Mailing Address Generators Site Address(it different than mailing address) Phone U.S.--—EPA ID Number 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name US,E Number Name and Site Address 8.Designated Facility kJ T, k M 4 Facility's Phone: 9a. 9b.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 Wt.Nol. 0 m Z 2. Uj 3, 4. 74.—Special Handling instmctions and Additional Information D'. f tit''T z I 15. GENERATOR'SlOFFEROR'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 EPAAcknowledgment 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. Month Day Year G faftors/Offeror's PTinted[,ypeT 'c b,Name is"7 -j 16.11ntemational Shipments El lmpj. -r6 U.S. ❑Export from U.S. Part of entry/exit: — 1`— Date leaving U.S.: 9 Transporter signature(for exports only): UW 17.Transporter Acknowledgment of Receipt of Materials S* t Month Day Year olle Transp.6 r 1 Printed/T d Name 0 al Month Day Year CL W - ", Signature Z Transporter 2 PrintedrUped Name 18.Discrepancy Ise.Discrepancy Indication Space Quantity El Type F-1 Residue ❑Partial Rejection 0 Full Rejection Manifest Reference Number: U.S.EPA ID Number 18b.Alternate Facility(or Generator) LL. Facility's Phone: Month Day Year C3 7B—c75g—ntureof Alternate Facility(a III r Generator) I Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment disposal,and recycling systems) LU !2. C3 20.Designpleid Facility Owner or Opera Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Month Day Year . rz -P I fln!ery,)dName Signature TED FACILITY TO GENERATOR EPA Form 8700-22(Rev.3-05) Previous editions are obsolete.