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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved,OMB No.2050-0039 UNIFORM HAZARDOUS I�Generator ID Number 2 P-a-gTj—of-F3'Em,,g,,c 11 Manifest Trackin IN b WASTE MANIFEST 1 �um Number 5.Generators Name and Mallin 1 9 Address Generators Site Address(if different than mailing address)8 7255 FLE ' Y rij q YS PDTH i Generators Phone: 2W7'- 6 Transporter I Company Name —A D5, tfw, U.S.EPA ID Number aj� 7.Transporter 2 Company Name U.S.EPA r)Number V N N 8.Designated Facility Name and Site Address V U.S.EPA ID Number 101 3 9 3,2,71 z" 0 - Facility's Phone -'1,1 il EA A 5 11 ga. 9b.U.S.DOT Description(including Proper Shoing Name,Hazard Class,ID Number, 11.Total 12.Unit HM and Packing Group fif ani 10.Center am 13.Waste Codes 1 No Quantity wt.Nol, IX 't'- r:4 if 7 li Lt ------ 3. D—L 1 Bi 1-uniTt' i 7-v LJ F t -t 4, 14.Special Handling Instructions and Addifional Information 't t 7. n ar-=,t D,,- hicielly declare that the contents i 15. G514ERATORVOFt�t��Nt I' a consignment are fully and accurately described above by the proper ahippjiiname,andclassified.packaged, marked and lable"p4aCarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipmentandI am the Primary Exporter,I Cadfly that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent I cartify that the waste Minimization statement identified in 40 CFR 262,27(a)(if I am a large quantity geni or(b)(if I an)a small quantity generator)is true. ted/Typed Name bignatureMonth Uay Year -6'VAA/8-7 I 16.International Shipments 0 Import to U.S. ❑Export from U.S. Port of eni Transporters nature for exports only): Date leaving U.S.: L W 17 Tran5porterAcknowledgment of Receipt of Materials 3raLl-- -i I vnntedi i yped Name Signature Month Day Year -S ql%hr- 19 U-,XW 109 Ito [/v Z Transporter I Printed Typed Name "I nature Month Day Year 18.Discrepancy I I 18a.Discrepancy Indication Space El o,sinbt, ❑Type El Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number. U.S.r i85.Alternate Fadliry(or Generates} EPA ID Number EcifLs Phone: LCO IE Signature of Fatality Month Day Year z 0 1 1 1 55 12.Hazardous Waste Report management Method Codes(i.e.,codes for hazardous wasle,treatment,disposal,and recycling systems) H141 2. 4. Designated Facility Owner or Operator; o -.a,a,Operator;Cerlificadon of receipt of hazardous�materials covered by the manifest except as noted in Item 18a le �LPrintedTTryppi Name Owner Ce Signature Month Day Year 8700-22 Zo a is sic lets EPA Form 8700- .(Rev.3-05) Us editions are b 1 r DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED)