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Please print or type,(Form designed for use on elite(12-pitch)typewriter.) Form Approved OMB No 2050,0039 2—Page,I of 3 Emergency Respn � UNIFORM HA Generator ID Number nso Phone 4Manifest Tracking Number WASTE MAP,4177 SKS 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing dress) Generator's Phone: 6.Transporter I Company Name U.S EPA 11)Number 7.Transporter 2 Company Name U.S EPA ID Number S, D Number 8.Designated Facility Name and Site Address 'f A UL _71 Facility's Phone: --- 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10,Containers 11 Total 12,Unit 13.Waste Codes HM and Packing Group(if any)) No, Type Quantity Wt.Nol. 411 2. LLJ 3, 4. 14 Special Handling Instructions and Additional information 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 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 EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generator's/Offeror's Printed/Typed Name Signature Month Day Year —A 16.International Shipments F__ 11 Import to U.S. ❑Export from U.S. Port of entry/exit: iE Transporter signature(for exports only): Date leaving U.S.: LWI 17.Transporter Acknowledgment of Receipt of Materials 82 Transporter)Printed/Typed Name Signature Month Day Year 0 Z Transporter 2 PrintedfTyped Name ,ftnature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space El QuantityE Type ❑Residue ❑Partial Rejection Full Rejection Manifest Reference Number: >_ 18b.Alternate Facility(or Generator) U.S.EPA ID Number :3 0 .<- Facility's Phone: Im -------[ LU 18c,Signature of Alternate Facility(or Generator) Month Day Year Z S2 19,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) co LLJ 1 2. 3. 4. 0 1 1 1 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete.