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r Please print or ype. o W S n for use on elite(12-pitch)typewriter.) 1 Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generetor ID Number 2.Page I of 3 Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST f�( r r - - 11003569357 G B F 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) CI l . s lu / Generators Phone' 6.Transporter i Company Name=Y — '" .( ,., U.S.EPA M Number 7.Transporter 2 Company Name U.S.EPA ID Number B.Designated Facility Name and Sile Address U.S.EPA ID Number Facith Is Phone: ga St.U.S.DOT Description(including Proper Shipping Name,HaxzN Gass.10 Number, 10.Containers 11.Total 12,Unit 13.Waste Codes HM and Patti Group[d any)) No. Type Quantity WtNol. t. Nora-ctrl. (r" . ( ti 1 pt 30 GAL ILI 2 2. 3. l 4 I 14.Special Handling Instructions andAdditlend Information 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 Wbelediplacanted,and are in all respects in proper condition to,transport according to applicable intem rtional 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 EPAAcknowledgmenlof Consent. I certify that the waste minimization statement identified in 40 CFR 21(f I am a large quantty,ger matin)or(b)(if I am a small quantity generator)is We. GerrendoeslOferoes PrinledlTyped Name Signature Month Day Year —JI iliF.I Shipments ❑Import to U.S. ❑Exporthom . Pod of entry/exit _ Transporter signature(for exports only): Dale leaving U.S.: CC 17.TronspoderAdmawledgni of Receipt of Nationals a Transporter 1 Prinled(Typed Name Signature - r Month Day Year O 13- Qz Transporter 2 PM Name Signature - - Day Yekr K r 18.Discrepancy 188.Discreperwy Indication Space ❑ Quantity 11 Type ❑Residue ❑Pallial Rejection ❑Full Rejeclior Manifest Reference Number 18b.Alternate Facility(or Generator) LLS.EPA ID Number J U W Facility's Phone. w 18c.Signature of Alternate Facility(or Generator) Month Day Year 2 19.Hazardous Waste Report Management Method Codes(Le.,codes for hazardous waste treatment,disposal,and recycling systems) 0 1. 2. 3. 4. 20.Designated Fadliry Omer or Operator.Certification of receipt of hazardous materials covered by the manfesl except as noted in Item 1 B 1 PnntetlRyped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete, GENERATOR'S INITIAL COPY