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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 I'.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST �,kj_,,(X 11.1;1 I I 1 00' 142413 JJ"f 5.Generators Name and MaillAddress Generators Sia Address(11 different than mailing address) 001J-�Atw 'W-i'1 4 I 1�3itiAkiu `-'A Generator's Phoc- ;(,I", 6.Transporter 1 tCompany Name U.S.EPA ID Number v) V1 I th� fl "A" / 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number 351"1 Old"A'vh1w!Z4��Afl 'VA.0 Facility's Phone: 9a. 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. fY 0 1 f N10 I K W-41 b 1�1a'4 N)1"Vi wo 2. LU 3. 4. 14.Special Handling Instructions and Additional Information h44ili,P' a)("A'41fv'44� ol?!71 we�zv hilpfq 1,1111", whifit M1144.11oqv k,14-0i"'0q1 Y 15. GENERATORVOFFEROR'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 c&*6nts of this consignment conform to the terms of the attached EPA Acknowledgment 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. [GeerTatc-rs/ erors PrIntedrryped Name Signature Month Day Year N"t, N,, a. -j 16.Internafional Shipments El Import to U.S. El Export from U.S. Port of entry/exit: Transporter signature(for exports only): Date leaving U.S.: 17.Tra*&derAcknovAedgment of Receipt of Mate rilials Transporter I Printedfryped Name Signature Month Day Year 0 an :L CL 2C Transporter 2 Printedfryped Name Signature Month Day Year tr 18.Discrepancy 18a.Discrepancy Indication Space El Quantity D Type El Residue El Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number Facility,Phone: Uj 18c.Signature of Alternate Facility(or Generator) Month Day Year 0 55 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LU 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/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY