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Please print or type. Form Approved-OMS No.2054-0039 UNIFORM HAZARDOUS]1.Generator ID Number T Page 1 of 3,Emergency Response Phone 4.Manifest tracking Number 3101 '5' p WASTE MANIFEST e:AL.i;fAj 15� ? 0061213 9 P; G©F 5.Generators Name and MailingAddress Generator's Site Address(if different than mailing address) r: } fi pi 6Ytt143585 . 3F4 , LUNI)BURGH S4, Generator's Phvne , 5)(XX l<)N,t-A U�i:% 6.Transporter I Company Name U.S.EPA iD Number t.a-„rC�VALLE WA,-,IL 0!L,.eft - 7.Transporter 2 Company Name U.S.EPA ID Number r:RU-A)t t e:: 8.Designated Facility Name and Site Address U.S.EPA ID Number ....'A., ;ti Facility's ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) 13.Waste Codes No. Type Quantity Wt.1Vvf. t. Q ?} ,+f•l-t ('1-4A f4A. fiji.PC( 43•:Se�F'A tf LLi rtr 3. i 4 14.Special Handling Instructions and Additional Informa6Dn 15. GENERATOR'SIOFFEROR'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 labeledlpiacarded,and are in all respects in proper condition fortransport 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 10 the terms of the attached EPAAcknowledgment of Consent. I certify that the waste minimization statement identifted in 40 CFR 262.27(a)('d I am a large quantity generator)or(b)(if I am a small quantity generator)is true. GeneratoeslOiferors PrintedlTyped Name Signature Month Day Year r t - 16.Inlemational Shipments ❑Impart to U.S. ❑Export from U.S. Port of entrylexif: Transporter signature(for exports only): Date leaving U.S.: W 17.TransporterAcknowledgment of Receipt of Materials LU Transpo fdr 11' ntedfTyped Name d Month Day YearCL r f QTtan"sporter2 Printed)Typed Name c =+ Signature r 'Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Partial Rejection ❑Full Rejection e ❑Residue Manifest Reference Number: 18b.Alternate Facility{or Generator) U.S.EPA ID Number U Facility's Phone: LU 18c.Signature of Alternate Facility(or Generator) Month Day Year Q F0 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems} c 1 2 a Notice:State of California requires generator to photocopy and mail to DTSC with so, 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Priniedi typed Name Signature P°0 BOX 400 EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENEWTOWSINl' cc T -