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t 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 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) �tzt >s A Generator's Phone: 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number 11-t1vt� l �gg""vo#'�Jaltayl"s1z('w 15""""("A��<t.'3'ktt rA t•+'-�t4?'t Q f I#«�S;'s Facility's Phone: 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 (if any)) $§ g No. Type Quantity Wt.iVOL 1 Ott f t d 'o :a O Z 2. W C7 3. 4. 14.Special Handling Instructions and Additional Information I-IffrJ"1I:'. f fg14A1,!4(f 'a ar® 11111(: V,r)tr,," 15. GENERATOR'S/OFFEROR'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 Exporter,I certify that the contents of this 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/Of,(eror'sPrinted/Typed Pame Signature Month Day Year e41 J 16.International Shipments �.- ❑Import to U.S. El Export from U.S. Port of entry/exit: z Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Transporter,l Printedrryped Name ...> Signature Month . Days Year Z Transporter 2 Printed/Typed Name Signatul ^,- Month Day Y r tY F- 18.Discrepancy 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection El Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J LL Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year Q 55 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) ® 1. 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/ryped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. INITIAL Y