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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Fort0pproved,OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2,Page 1 of 3 Emer ency Response Phone 4.Manifest Tracking Npmber WASTE MANIFEST f� �� W 5.Generators Name and Mailing Address " Ganeralor's ite'Address(if different than malting address) 1:14 A GeneraorsPhone; V 6.Transporter 1,company NameUTEPA ID Number 7,Transporter 2 Company Name U.S.EPA ID Number 8.DesOgatgd FaClity Ne d S tg f)dgr es i.r: U.S.EPA ID Number i4j;,t 1'. 11tti.tlikL�/�1.'fc 1.,16 Facility's Phone:' 9a, 9b.U.S:DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10,Containers 91 r Total 12,Unit 13.Waste Codes HM and Packing Group(if any)) No, Type Quantity Wt.Nol. 1. Eh.;it,1:Fe'tff<s;;+Ff�12,'t .iYV!) 4�Ax:'t�il�' cttl',fi. r(il,, ,li?�� iisastlt� t,1br7 fa i� Or Z z, w 3, 4. r 14.S ectal Hetidlin instructions and Additional Information J pi;ltt„fit 1,g1g ''+ � `dF 4 k'p 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,tabdI6dlplacarded,andateIn all respect's 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 df tljis consignment conform to the terms of the attached EPAAcknowledgment of Consent. I cert1fy that the vl8-s10 .,minlmization statement Ideritiiied In 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if i m a small quantity generator)Is true. Signatk)e Month Day Year [05en7e,—ra!t.q�s/O erors rlptedlTyped Namme T v 16.Interna ionai Shipments ❑import to U.S. ❑Export from 5: Port of entry/exit:. z -. U.S.,- — Transporter signature(for exports only); Date leaving U.S. U.1 17,Transporter Acknowledgment of Receipt of Materials N' Transpor(er 1 Printed/Typed Name ;2-e2.., Sign ure b, a - Month Day Year - _,m, .X�' rn�porter2PrintedfrypedName Signalurea ��pR Month Day Year H 18.Discrepancy 18a.Discrepancy indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number r 18b.Alternate Facility(or Generator) U.S.EPA ID Number J_ {.7 t8+ Facility's Phone: 18c.Signature of Alternate Facility(or Generator) Month Day Year i N19.Hazardous Waste Rgport Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) O 1 2 3 4 ( � I �--^' � I 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted In Item 18a Printed/Typed Nary 0 t r t Signature '` Month 'Day Year t � , EPA Form 8700-22(Rev.3-05) Previous bditions are obsolete. TFdANSPORTEl 'S COPY I