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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 �NIVORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST JJ ,.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) i'•.I 0!II(!m1oi's Phone: t. I ranspoilei 1 Company Name U.S.EPA ID Number ansporter 2 Company Name j lI U.S.EPA ID Number 8 Dnsignatnd Facility Name and Site Address U.S.EPA ID Number f_^f I m illry's Phone: 9 91i.U.S.DOT Description(including Proper Shipping Name,Hazard Class,fD Number, 10.Containers 11.Total 12.Unit I IM and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes LL1 Z 2. lU Ll i. 4. Irl.;[)eclat I Immling Instructions and Additional Information vt 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 labeled/placarded,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 I xpoiloi,I rntlily that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I r.a lify Ihal the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if!am a small quantity generator)is true. eneinlui'slO(fe,rw's PrinledlTyped Name Signature Month Day Ysar 1f,.InlemalionalShipmenis F- ❑ Import to U.S. ❑Export from U.S. Port of entry/exit: T ranspoi ler signalure(for exports only): Date leaving U.S.: ua 17.Transporter Acknowledgment of Receipt of Materials o; Transporter 1 Printedll yped Name Signature Month Day Year O 1 ransporler 2 Printed/Typed Name Signature< g Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: F 181).Alternale Facility(or Generator) U.S.EPA ID Number J U U- Facility's Phone. a 18c.Signature of Alternate Facility(or Generator) Month Day Year Q 55 19.1 lazarclous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LU 1 + 2' 3 4. y 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrinledlTyped Name Signature Month Day Year I_PA Fonn 8100-22(Rev.3-05) Previous editions are obsolete.