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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,Generator ID Number _ r�� 2.Page 1 of 3.Emergency Response Phone <.Manifest Tracking Number WASTE MANIFEST I "I -' JJK 5,Gene,6i,! f;x Navys Name and Mating Address Generator's Site Address(if d�erent than mailing address). Generatoas Phone: 6 Transc'rfer 1 Company Name U.S.EPA ID Number 7 Transpgrter 2 Company Name U.S.EPA ID Number 8.Desigrnated Facility Name?,40. 501 L1 t-LLxif3 LLC C A r U.S.EPA ID Number i1tCt tltltur.t A �1 'rJl FaciHi 's phone: i ga 9 U S.DDT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM 2PC Packing Group(d any)) No. Type Quantity Wt.IVol. 13.Waste Codes O I w z LM C7 i 14 Special H3ad!mglnslructionsand AddihonalIn iomatlon %017 t4trbut M."V91 473 !r. ,. ,A'Ait, fle;tr Pr�.�r Pi`ii (:loCl.turt - • .rl «�yi.trl-�tr-y r�-' ,•tt��,' t 15. GENERATOR'S10FFEROR'S CERTIFICATION:i hereby declare that the contents of this oonsignment are fully and accurately described above by the proper shipping name,and are classified,packaged. markad and labeledlpecerded,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 terns of the attached EPA Acknowledgment of Consent. I cer l�that the waste minimization statement identified in 40 CFR 262.27(a)('d I am a large quantity generator)or(b)(f I am a small quantity generator)is true. Gereratces Oiferor's PrintedlTyperi Name 5ignature Month Day Year 16.Int?maLonal Shipments Z ❑Import to U.S. ❑Export from U.S. Port of entry/el Transporter signature(for exports only): Date leaving U.S.: LU 17,Transpciter Acknowledgment of Receipt of Materials Transporter I Printedfryped Name Signature Month pay Year O IL rs Q Transporter 2 Pnrited4yped Name Signature Month Day Year r 18 Discrepancy 18a.Discrepancy Indication Space ❑ Quan. �' El Type ❑Residue ❑Partial Rejection ❑Full Rejection 18b.Ahemate Facility(or Generator) Manifest Reference Number: U.S EPA IQ Number J U Facility Ph^ne. W 18c Signature ofAftemate Facildy(or Generator) F Month Day Year a z 19 1-137ardcus Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 1 2. 3. 4. 20.Designated Facility Owner or Operator.Certrfication of receipt of hazardous materials covered by the manifest except as noted in Item]Be Punted Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY