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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB NoI2056-0039 1 UNIFORM HAZARDOUS .Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.ManifestTraekmg Num , j 7t d f a WASTE MANIFEST .+} c s ' t 9� 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) Generator's Phone: ...,..;. 6,Transporter 1 Company Name� U S EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facili Natne an'd Si 00ress U.S.EPA ID Number Wt'- . Facility's Phone: i>� HM9b.U.S.DOTDescription(including Proper Shipping Name,Hazard Class,ID Number, ;,10.Containers,., „ 11.Tot?[ 12:Unit 13:Waste Codes and Packing Group(if any)) No, Type Quantity Wtivol. . 1 i.,•,:4) Y r�..5 �+I r i r.:rYt �':' F �rr1 t:,r„ f c ,r't S+��.f .. r :. t..'i1, .1""-'' .r'�t! '. W 2 LU 3. 4, 14 Special Handling Instructions and Additional Information y yJ Py -k 15. GENERATOR'S/OFFEROR'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,package '"d marked and Iabeledlpiacarded,and are in all respects in proper condition for transport according to applicable international and national.govemmental regulations,If export shipment and t am the Riima'ry, ' Exporter;]certify that the contents of this consignment conform to the terms of the attached EPAAcknowiedgment of Consent. ' I certify thatIthIa waste minimize Uon statement Identified in 40 CFR 262.271(a)(if I am alarge quantity generator)or(b)(ffl am a small quantity generator)Is true. rn.rato(s/Offeroes Printed/Typed Name Signature d 'Month Day• Year —i 16.International Shipments ,' i— ❑Import to U.S. ❑Export from U.S. Port of-e' z Transporter signature,(for exports only): Date leaving U.S UW 17.TransporterAcknowledgment of Receipt of Materials TranspoRerl•P'nt/jedffype/fdName Signature Month Day Year V) '�.i') 6.1✓'t ! `- Jf C�'J t N'."f'.:.f... Jrr`r I y �r ,1 ZQ Transporter 2 Printe"ped Name Signature Month Day Year Q.0 F- 18.Discrepancy 18a.Discrepancy Indication Space Quantity ❑Type ❑.Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number. 18b,Alternate Facility(or Generator) U.S.EPA ID Number J U U.; Facility's Phone: W 18c.Signature ofAltemate Facility(or Generator) Month Day Year d r, 19.Hazardous Was d Rgport Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 2. 3. 4, 20.Designat4d Facility Owner or Operator.,Eertificatlowof receipt of hazardous materials covered by the manifest except as noted imitem 18a Pdnted/Typdd Nam' - , Signature' rMorilh Day Year, EPA Form 8700-2 ., 2(Rev.3-05) Previous editions are obsolete. TRANSPORTER'S COPY