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Please print or type.(Form designed for use on elite(12-pitch)tyDewriter.) Form Approved.OMB No.2050-0039 1.Generator ID Number 2.Pa e i of 3.Emergency Res nse Phone 4,Man s Tra kin Num r UNIFORM HAZARDOUS g g y p° FLE WASTE MANIFEST C�+L� � 1 i— ,r a�'�i. b r 1,� 2 f y 5.Generators Name and Mailing Address Generators She Address(if different than mailing address) MEIPMOCA UNfed Soaker DW46& (SWM r;tpi 17M 7hwiw, :rt mme4"e, Chi t M` Generators Phone: 8.Tran poder 1 ComppTror ny Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number B DesignAted Facility Name and Si€e Address U.S.EPA ID Number us hDOR)m w kc P0 JJOX Bratty, QV i� Facility's Phone: T?5-SS-1-Z'" ' ga, 91b.U.S.DOT Description(including Proper Shipping Name,Hazard'Class,11)Number, 117.Containers 11.Total 12.Unit HM and Packing Group(If any)) No. Type Quantity yyJVol. 13.Waste Codes 4.FIG19 w z 2. w = I 3. e i 4. i .14.Special Handling Instructions and Additional Information � . , HOW W trtxllRM[a IF DI 161, 0 EM417v 13WAr7'.0:71 uAlai��•' 15. GENERATOR'NOFFEROR'S CERTIFICATION: i hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are ciassified,packaged, marked and lebeledlplacarded,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 EPAAcknowledgment of Consent. I certffy that the waste minimization statement identified in 4C CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. G,eneratoeslOfferors RrirnedFryped Name SlWature Month._ a } e ' � t 16.International Shipments a ❑Import to U.S. ❑Export from U.S. Pan of entrylexit Transporter signature for exports only): Date leaving U.S.; W 17.Transporter Acknowledgment of Receipt of Materials Trarj e 1 prigtedlfyped Name Signature lMonth ear �1J1J CL �� 1 Za Transporter 2 Printedrryped Name Signature Month Day Year iY F-� 18.Discrepancy 18a.Discrepancy indication Space ❑ Ouanti Residue ty ❑Type ❑ ❑Partial Rejection ❑Full Rejection Manifest Reference Number. N 1$b.Alternate Fadl ty{or Generator} U.S.EPA ID Number J_ L) a rl Faclf s Phone: LOU 18c.Signature of Alternate Facility(or Generator) Month Day Year a z 19.Hazardous Waste Report Management Method Codes(Le.,codes for hazardous waste treatment,disposal,and recycling systems) 2. 3. 4, 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in hem 18a Pdniedfryped Name Signature Month Day Year FPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY