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Please print or type,(Form designed for use on elite(12-pitch)typewriter):. Form Approved.OMB No.2050 039 UNIFORM HAZARDOUS 1.Generator ID Number 2 Page 1 of 3,Emergency Response Phone 4.Manifest Trackmg Number s WASTE MANIFEST ' ` , ? t /' " JJ 5.Generator's Name and Mailing Address Generator's Site Address(if different thanrnailing 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 Facility Name and Site Address e- U.S.EPA ID Number 144 l,fc .r✓f JG.:. ajr .,. Facility's Phone: u ,.� � �61, ga 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.N01. Z 2. W c9 3. 4. 14.Special Handling Instructions and Additional Information TL 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,packaged, marked and 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 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. Generator's/Offerors Pnnted/ryped Name Signature Month Day Year --r 16.International Shipments F— ❑import to U.S. ❑Export from U.S, Port of entry/exit: Transporter signature(for exports only): Date leaving U.S.: w 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day Year Q Tran sp5 rter 2 Pdntedfryped Name J Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space El Quantity El Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b,Alternate Facility(or Generator) U.S.EPA ID Number ca LL- Facilitys Phone: N18c.Signature of Alternate Facility(or Generator) y r Month Day Year Z V; y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LU 1. 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a ped Name Signature Month Day Year r rintedlTy EPA Form 8700.22(Rev,3-05) Previous editions are obsolete. TRANSPORTER'S COPY