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Please print~type.;Form designed for use on elite(12-pitch)typewriter.) Form Aooroved.OMB No,2050-0039 UNIFORM HAZARDOUS 1 Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST , U 0 9 12_5 5 6 FLE 11 5.Generator's Name and Mailing Address- Generator's Site-Address{if diff ree nt-than mailing address) 1-1Wj T. St 6 Transporter 1 Corl NartlerU.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number B.Designated Facility Name and Site Address U.S.EPA ID Numoer LOS E W PO BM 5�M KW 95,11 M#M S �tty N ;�i."100M Fad s`�Fiane`�� 98 9b.U.S.DOT Description(irduding Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group('d any)) 13 Waste Codes No. Type Quantity Wt.Nol. O ti ,��ii' lC lliRs 111AS1t'.�f;� ,[3.c).'i.� 11f7 l t i P I►.�a = x x4.9. P[ -—.... z 2. W W i 3. I i i 4. ------------- 14.Special Handling Instructions and Additional Irnormation Plow.(idm—bw 113(W l.11)tt09"* Q13•tl 44 ,-� 15GEN ERATOR'StDFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and aocurate#y described above by the proper shipping name,and are classified,packaged, marked and labe4diplacarded,and are in all respects in proper condition lar transport according to applicable international and national governmental regulations.if export shipment and I am the Pnmary Exporter,I certffy that the contents of this consignment conform to the berms of the attached EPAAdTow iedgment 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. Hereto s! ems Printed/Typed Name tqnature Month -Fal 16.International Shipments ❑report to U.S. z I ❑Export from U.S. Port of entryfil -- T-ansporter si naturefor exports or : Date I U.S.: 17.Transporter Adoiowledgment of Receipt of Materials �• i Transporter 1 Prirnedlryped Name Sigrl fM yesr QTransporter2 Printedrryped Name Signature Month Day ear tY 18.Discrepancy 18a.Discrepancy Indlcatior Space ❑ Quantity ❑Type ❑Residue Ell Rejection ❑Full Rejection Manifest Reference Number: 1 O Alternate Facility(or Generator) U.S.EPA ID Number J a Facility's Phone: L 18c.Signature of Alternate Facility(or Generator) Month Day Year a Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous malenals covered by the manifest except as noted in Item 18a Prinledrryped Name Signature Month Day Year EPA Form 8700-22(Rev.M5) Previous editions are obsolete. GENERATOR'S INITIAL COPY