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Please print or type. (Form designed for use on elite (12-pitch) typewriter.) Form Approved. OMB No. 2050-0039 UNIFORM HAZARDOUS 1 1. Generator ID [lumber 2. Page 1 of 3. Emergency Response Phone 4 Manifest Tracking Number WASTE MANIFEST r Y L r. t 'i 1 1 �Qt_ ..� � . L-:�. ®AT S. Generators Name andMailing Address f t I.,. r Ge rators Site Address (itdifferent than ling address) t j, I_ _ 'i3'- � -1 , .. itl D e / rr ` rn ¢ t i�tL Iter i "E t11 %t Generators Phone: <'Ut' - ','+= � , (.• 6. Transporter l Company Name U.S. EPA ID Number t i _.'Yf itfl-t L �i7 ¢ L 1� `' `t_f 11 .�� ._. l rt � h r 1,1. ••. } I :fUnl.7. �If % 7. Transporter 2 Company Name U.S. EPA ID Number ; e ' �r,4ro7 n ,6ra1 5 8. Designated Facility Name and Site Address U.S. EPA ID Number 11 „f I t ) Facilints Phone: ' vi . r)'"'- ga 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 (it any)) No. Type Quantity Wt.Nof. a. 1 1 - 'i i. . ', I ' , tJ IiJI r c, . .. j. t : I ; +::, I � • ' 'I 'i LIJ j z 2 old r te= .1�t3 �. ( FY , rt 1 4. _ _ I A. Special Handling Instructions and Additional Information i sJiln le, r ,. �rtti t > , i, ..v,n! . � ., lr .:rt (. t.r .: r;I-�; . r . rirli�a , [ t , •r -.,, rt -; L ' . f. 15. GENERATOR'S/OFFEROR'S CERTIFICATION: 'I hereby declare that the contents of this consignment are fully and accurately described above by theproper shipping name, aN are classified, packaged, marked and labeledlplacarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. If expel shipment and I am the Primary Exporter, I certify that the contents of (his consignment conform to the terms of the attached EPAAcknowledgment 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. Generators/Offerors Printed/Typed Name Signature Month Day Year ri 16. International Shipments i— ❑ Import to U.S. ❑ Exporl from U.S. Pod of entry/exit: z Transponer signature (for exports only): Dale leaving U.S.: ad W 17. Transponer Acknowledgment of Receipt of Materials � Transponer 1 Printed/Typed Name Signature --. Month Day Year O a 1 QTransponer2 Prinled/fyped Name ' - Signature Month Day Year t— 18. Discrepancy Its. Discrepancy Indication Space ❑ Quantity El Type ❑ Residue ❑ Padial Rejection ❑ Full Rejection Manifest Reference Number: INe. Alternate Facility (or Generator) - U.S. EPA ID Number U Facilii Phone: w 18c. Signature of Alternate Fackity (or Generator) Month Day Year Q Z CD n 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 2. 3. .- 4. 11 F f 20. Designated Facility Owner or Operator: Codification of receipt of hazardous materials covered by the manifest except as noted in Item Ills Printed/ Iyped Name Signature Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY