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6 66 70 40 i r t Form designed for use on elite (12-pitch) typewriter.) �� Form Approved . OMB No. 2050-0039 Please print or type . ( g ( p ) yp ) UNIFORM HAZARDOUS 114 Generator ID Number 2. Page 1 of 3. Emergenc sponse Phone 4. Manifest Tracking Number I WASTE MANIFEST �:r i z U �Ft. � generators Name and Mailing Address ' ' Generator's Site Address (if different than mailing address). � t P 3 5 Generators Phone: ("i 0C •- ( ' ) S S- 6. Transporter 1 Company Name IJ S . EPA ID Number fir t. -` 3" P ,° L tJ i t ; ! 7 J 7 � t"7r . t+. A 11 i _ rA !` 7c, c t"1it 7. Transporter 2 Company Name U.S: EPA ID Nbm5er 0 016 8, Designated Facility Name and Site Address U.S. EPA ID Number �� ly } '''?. 4 A ? Sr !; 3 C � V Faci ity's Phone: t — �7 ` 1. 1 , 3a >(3 +t P3 y n ga 9b. U .S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10 . Containers 11 , Total 12, Unit HNt and Packing GroutSp (if any)) No. Type Quantity Wt./Voll13. Neste Codes 4 AJ 2% O f' m rr LU 3. 31 ' 7 � 11ar°t 9� x� r ':i �✓' . �l / ! �`u 1r S� �vV II ? � L j, � 9 ± s S Thew e 10 t? �4 Special Handling Instructions and Additional Information 5 " ;r - =sem S1tiJ i I t `' r IL65 ? 1 �,_ �1r? ifti (� �� L9i C � r � Llrtif� 1I � �v e /d' l !"" il� F? fV ( � " v 15:' GENERATOR'SIOFFEROR'S CERTIFICATION : I hereby declare that the contents of this consignment are fully and accurately d6scribed above by the proper shipping name, and are classified, packaged, marked and labeled/placarded, an 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 cedibj that the contents of this consignment conform to the terms of the attached EPAAcknovdedg�ent of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generyroii) or (b) (if. 1 am a small quantity generator) is true. Generatdrs/Offeror's Priinnted/Typed Name f Lure a onrt� ay� 2a ==I 116, International Shipments F ❑ Import to U.S. ❑ Export from U .S. Port of entry/exit: ? Date leaving U.S. Transporter signature (for exports only): 9 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 PrintedrTyped Name Signature Alonth D,ay Year Z Transporter 2 PrintedlTyped Name <ignatdre ' Mlo fh Oay Year H 18, Discrepancy 18a. Discrepancy Indication Space ❑ Quantity T1P❑ e ElResidue ElPartial Rejection ❑ Full Rejection Manifest Reference Number: F 18b. Alternate Facility (or Generator) U.S. EPA 10 Number v Facility's Phone: w 18c. Signature of Alternate Facility (or Generator) Month Day Year Q Z 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 2. 20, Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrintedlTyped Name signature Month Day Year EPA Form 8700-22 (Rev.- 3-05) Previous editions are obsolete, DESIGNATED FACILITY TO GENERATOR STATE ( IF REQUIRED)