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Please prat-or type.`Fonn designed lbr u'se on elite(12-pitch)typewriter.) Form Approved OMB N. 2050-0039 UNIFORM HAZARDOUS 1 Generator ID Number 2"Page Sof 3.Emergency Response Phone ]i016987587JJK est TrackingNumber - WASTE MANIFEST GrL '.�" 5.G rer4l�rs.�lar�r a a-d Ma7ng Address Generators Sita Address(N df larent than mairing address r ? 6W3 N t • r' rr, k:A 1 Generators Phone: _ ` ` {id•`.f3$ -r�"s. 5.Transponer'i Company Name ?n v c2m Geofie'hf �+11T�.1;-+. to U.S.EPAIDVhsl:b�r 7.T 7pcider2 Company lame y. U.S.EPA ID Number 8.DesiS�al�d ly�lame�and Site Address U.S.EPA ID.Nurraber... ;cTJi�131tt at, - . FacilitVs Phone: ga 9b.U.S.DOT Description(nclsrdin'g Proper 5h pp ng Name,Hazard Class,ID Number, S0.Containers 1S.Total t2.Unit HM and Packing Group(d any)) No. Type Oua otaltity 12.Uri 13.Waste Codes Y 1. :"�r:': :?•�;4�, 1'ta'��.ftiTX:+RS� 1'..Ya,�tE:aG�LrL•�(iCO� HI'.5Gft3'?P.t � met : err W 2, W 3. 4. 14,S Handlfng Instructions and Additional Information m+:3r 171 Li3E GLO ES ;r•�sf�r �x�o ` 15. GENERATORISIOFFEROR'S CERTIFICATION: I hereby declare fhat the contents of this consignment are fully and accuratelydesabed above by the proper sNppfng name,and are classified,packaged, marked and tabdedlplacarded,and are in all respects in proper condition for transport acmrdmg to applicable international and nations!governmental regulations.If expoR shipment and I am the Primary Exporter I certify that the contents of this consignment conform to the terns of the attached EPAAdmowledgmerd of Consent I cefffy that the waste minimization statement ideri iced In 40 CFR 28227(a)C41 am a large quantity generator)or(b)RI am a small quantity generator)is true. Generators/OffeforsPrintedffyped ame Signabrre. Month Day Year 15.International Shipments - ❑Import to U.S. enbylexit_ Export from U.S �` Port of --- Transporter signature(tar exports orJy): ❑E Date le U.S LW 17 TranspotlerAdmowledgmentofReccipioiMateriais / � Mor � Transporter t Printe jpeh ame Keffip-i Sere l'� J �Io (ffffJ� it Da L4 ` W Transporter 2 Pdntedlfyped Name I Signature 1 Month Day Year 18.Discrepancy 18a Discrepancy indrafon Space ❑ OuanSty ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection 18b Atxmate FaciTty(or Generator) Manifest Reference Number: r U.S.EPA ID Number WIn Fadl tys Phone, I 18c,Signature of Altemats Facility(of Generator) z -- Month Day Year H19.Hazardous Waste Report Management Method Codes(.e codes for hazardous waste treatment,disposal,and recydtng systems) ms) 1' 12, 3 4 20,Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted inItem 18a Primew l yped Name Signature Month Day Year EPA"ffn B700-22;Rev.3-05) Previous editions are obseete TRANSPORTERS COPY