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Form Approved,OM&No.2050 0 39 Please print or type.(Form designed for use on elite(12 pitch)typewntet'h,a�. PP 1.Generator ID Number 2 Page'1"of 3 Eme'r'gency Response Phone 4,.Manifest Tracking Number UNIFORM HAZARDOUS 1 Z`'9 r, 7 9 JJ K , WASTE MANIFEST �"" � •' ''�� 5.Generator's Name and Mailing Address " Generators Site Address(it different than mailing address) Generator's Phone: 6,Transporter 1:Company Name" U,S EPA ID Number :.��t rte ` ., .. _. r�4, i Sg�,�pyrle -t•nrii'. 7 Transporter 2 Company Name U.S.EPA ID.Number { 8 Designated Facility Name and Site Address Cat's �Y ��:(' ray r$ c.�" o,aC: U.SEPA ID Number r �Y Facility's Phone ?�_: _ . �....}•;' � , ga 9b.U.S.DOT Description includin Proper Shipping Nae,Hazard Class,ID Number;,;, 10.:Containers.;, Total'., 12.Unit , ( g p pp g 13:Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. tL 3. 4.' 14,Special Handling instructions 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 labeled/placarded,and 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 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 26227(a)(if i am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generators/Offerors Pdntedrryped Name Signature Month pay Year j 16.International ShipmentsEx trY ❑Import to U.S, ❑ port from U.S. , Port of en /exit: z Transporter signature(for exports only): Date ieaving U.S.: 17.Transporter Acknowledgment of Receipt of Materials LLJ Transporter 1 Printedrfyped Name ? Signature ;# Month Day Year y is , t.y I ;,E,�i• ; �� z Trensborter 2 PrinledlTyped Name Signature ! Month .rDayYear Ce 18,Discrepancy 18a,Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue y ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J ' uQ.. Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) y Month Day Year Q y19.Hazardous Waste Report Management Method Codes(Le.,codes for hazardous waste treatment,disposal,and recycling systems). 0 1 2. 3. 4. 20,Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest exceptas noted in Item 18a Printedrryped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. TRANSPORTER'S COPY i i