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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 1 UNWORM HAZARDOUS 1 1.Generator ID Number 2.Page 1 of 3.Emergency Response Manifest Tracking Number WASTE MANIFEST I-?� 4 J 1 0021822408 Mrs 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) 7 APH I 7011� �,' 1 bV i'-2,t ',kiidh V", �,IW+At o 'A 9'a.?k Generator's Phone: �! " tl I st t I 6.Transporter I Company Name U.S.EPA ID Number .4;1 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA 10 Number -A C)ld slS,6i'P2104, A kelllt-vumi 41v,i.'A 94,a,A'9 3RO-O'O I 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)) No. Type Quantity Wt.Nol. 1. RQ, 0 I,T fv,'r+t I S�e r,I W,-I tea I Z 2. UJ 3, 4. 14.Special Handling Instructions and Additional Information filt- ir, I"A,14" wt-al 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/Offerors Printed/Typed Name Signature Month Day Year Rj,xn UsriT '�L Lat -�LkAacL L -J16.International Shipments El import to U.S. EJ Export from U.S. Port of entry/exit: Transporter signature(for exports only): Date leaving U.S.: UJ 17.Transporter Acknowledgment of Receipt of Materials 1E Transporter I Printed/Typed Name Signature Month Day Year 0 a- co Q[Transporter 2 Pri d/Typed Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space -1 Quantity El Residue F-lP,rti,l Rejection Rejection F 1:1 Type El Full Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number :3 w Facility's Phone: 0 LU 18c.Signature of Alternate Facility(or Generator) Month Day Year !R I Z 0 US 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0LU 1. 1 2. 3. 4. Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a - Is �n Typ ndad Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY