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Please print or type.(Form designed for use on elite(12-pitch)typewriter) Form Approved,OMB No.2050-0039 1.Generator , - an � r ID Number 12.Pagelof 3�EMeir 4.M if �JTJ�alinNugr UNIFORM HAZARDOUS WASTE MANIFEST - `�' 1 0 35 SKS 5,0eneralor's Name and Mailing Address Generator's Site Address(ff different than mailing address) I% eV. Generatoes Phone: 6, !7 U.S.EPA ID Number 7.Transporter 2 Company Name U.S,EPA IQ Numbor 8.Designated Facility Nam and Site Address 0i L 'i ra L L ii,m U.S.EPA 11)Number Facility's Phone: ga. 9b.U.S.DOT Q#scription(including Proper Shipping Name,Hazard Class,10 Number, 10.Containers11.Total. Unit 13,Waste Codes HM and Packing Grqup(if any)) No, Type Qu i2.Unit 2. Uj 4. 7 7 7 7 =77—7-7-3 "T 14.Special Handling Instructions and Additional Information c' L f; 1- G!71' TO RZT4,,T!� N� 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignaarit are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labeiedtpiacarded,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 term of the attached EPA Acknowiedgmem of Consent I certify that the waste minimization statement identified in 40 CFR 262.27(a)(it I am a large quantity generator)or(b)(91 am a small quantity generator)is true. Generator'-st'Offeroes Printed(ryped Name signature Month Day Year_ + 16.International Shipments L1 Import to U.S, ❑Export from U.S. Port of entrylexit Transporter signature(for exports only): Date leaving U.S.. LO: 17.Transporter Acknowledgment of Receipt of Materials U - I Transp9rer I Prnted/Typed Name Signature Month Day Year Z Transporter 2 PrintedfTyped Name Signature 'r Month Day year 18.Discrepancy 115a.Discrepancy Indication Space ❑ Quantity El Type 0 Residue EIPtial R.0,1ticri ❑Full Ratecliion Manifest Reference Number, 18b.Alternate Facility(or Generator) U,S.EPA ID Number Facility's Phone: Uj 18c.Signature of Altemate Facility(or Generator) Month Day Year 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 J 3. 4. 20,Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Rom 18a Printed(Typed Name Signature Month Day Year EPA Form 8NQ-22..&y.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY