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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 1D Number 2.Page t of 3.Emergency Response Phone 4.Manifest Tracking Number p WASTE MANIFEST ` i f ' ,.r!` t ` - G D F )s !,r' 5.Generator's Name and Mailing Address`r Generator's Site Address(if different than mailing address) k j] �� '.,;, 4 i�jai i •' t>t• 6� � f.k. Geniraiors hone f 1 t 4t •};., 6.Transporter 1 Company Name U.S.EPA ID Number 7'=❑5i "i 1 M�. '..1_I,z ¢ -. '•._'1 "_f t';'t`is` .t w 7.Transporter 2 Company Name y /! U.S EPA IQ Number 71 S B.Designated Facility Name and Site Address " U.S.EPA 1D Number r.� ra } ♦ :r{ �.0 ��.jhgtr.:./s.��,t k ,f,� ypE,4,.��,�.�'ti G., -17't"(' n3. 3 iRS�i A Facllitys Phone: 54_31'20'2 14, ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 16.Containers 1t.Totai 12.Unit HM and Packing Group(if any)} 13.Waste Codes f No. TypeLU Quantity Wt.Nol. Z 2. UJ c7 3. 4- 14.Special Handling Instruclions and Additional Information 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 Iabeledlplacarded,and are in all respects in proper condition for transport according to applicable internatiopal 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 t.'<onsent. r I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)Vap 9,SMall quantity generator)is true. Generator's/Offeror's_.PrintedfTyped Name Signature ;r r Month Day Year{d fi `.t JJ Wernational Shipments z ❑Import to U.S. ❑Export from U S Port of entryfexit: Transporter signature(for exports only): 9.e'-' Date leaving U.S.: LW IT TransportetAcknowledgment of Receipt of Materials Ll a Tr nsporter 1 Printedityped Name f Signaturo Month Day Year EL r ; Z Transporler 2 Printed/Typed Name Si nature Q 9 Month Day Year rY 7�. 18.Discrepancy 18a.Discrepancy Indication Space ❑ quantity ❑ Rejection Type t J Residue ❑Partial Re YA 1' ) ❑Full Rejection r Manifest Reference Number: 18h.Alternate Facility(or Generator) U.S.EPA ID Number j U LL Facility's Phone: w 18c Signature of Allernate Facility(or Generator) Month Day Year a z 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 noled in Item 18a PrintedlTyped Name y. Signature Month Day Year EPA Farm 8700-22(Rev.3.05) Previous editions are obsolete. GENERATOR'S INITIAL COPY