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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No?050 1.Generator ID Number 14.Manifest Tracking UNIFORM HAZARDOUS 2.Page 1 of ,3.Emergency Response Phone Number A L_J JJK , WASTE MANIFEST C.." —V tj 5.Generators Name and Mailing Address Generatol's SiteAddress(if different than mailing address) s 'Ger s Phone: 5 iL) 6.Transporter'1 Company Name U.S.EPA ID Number 7,Transporter 2 Company Name U.S.EPA ID Number 8.DesignAted�FacilityName,apqsiteAq5fess,,,,, U.S.EPA ID Number Facility's Phone: 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total 12.Unit HM and Packing Group(if any)) 13.Waste Codes No, Type, Quantity Wt.Nol.., 2. LU 0 3. 4. 14.Special Handling in structions and Additional Information Pt 15. GENERATOR'S/OFFEROWS 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 an'-d'labeled/placarded,and are in all respects In proper condition for transport according to applicable intemational 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 EPA Acknowledgment of Consent. I certify that the waste minimization statement identified In 40 CFR 262.27(a)(if I am a large quantity generato or(b)(if I am,a small quantity generator)is true. Generators/Offerors Printed/Ty ed Name p Signature Month Day Year _j 16.Intematilonal Shipments D import to U.S. ❑ Export from U.S. Port of entry/exit: Transporter signature(for exports only): Date,leaving U.S.: LLJ 17 ft Tr6nsporternowedgment of Receipt of Materials Transpbrterjj.FFintddfryped Name SignatureMonth Day Year 0 Z Transporter 2 Fnntedf typed Name signature 0 Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space El Quantity EType ❑Residue El Partial Rejection 0 Full Rejection Manifest Reference Number. 1= 18b.AJtemate Facility(or Generator) =I U.S.EPA ID Number CV LA- Facility's Phone: LOU 18c.Signature of Aftemate Facility(or Generator) onth Day Year Z 19.Hazardous Waste Report Management Method Code-s-(I.e.,codes for hazardous waste treatment,disposal,and recycling systems) 4. 2. 3. 121 Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a P t yp, Signature dfnd Name Month Day Year 21 EPA Form 8700-22(Rev.3-05) Previous edition6 are obsolete. TRANSPORTER'S COPY