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V Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFESTi, z?'I ^- ` 81"414 JJK i-�Ai-V)26 dt1 004.1 4 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) Y'*h'-T *;ul V-who pit AWN I I A48 I V,1,N)1€ N 1 3 1` bTt <<*; wi 1! "I i'--+.`.A Generators Phone: I s q�A 6.Transporter 1comPany Name U.S.EPA ID Number 77fransporter 2 Company Name U.S.EPA ID Number B.Designated Facility Name and Site Address U.S.EPA ID Number Ctwvficdl*%Yhyle ('41 1:4--Imt' Q, 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(d any)) No. Type Quantity Wt.Nol. 1, psi f a W109,111`4141 iff 00 1 Ifl, rXJ0 I Y 4 kvi Z 2. uJ 3. 4. 14.Special Handling Instructions and Additional Information Pwfi-, fif, 7 1 wc'w 15. GENERATOITSIOFFEROR'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 intemational 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. GeneratoestOfferors Printed/Typed Name Signature Month Day Year L J 16.International Shipments Import-t-U.S ❑Export from U.S. Port of entry/exit: 9 Transporter signature(for exports only): Date leaving U.S.: IX 17.Transporter Acknowledgment of Receipt of Materials Transporter I Printed/Typed Name Signature Month Day Year 0 LEE L� 1,1'� -7 CL Transporter 2 Print6dfTyped Name Signa Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space 0 Quantity ❑Type Residue D Partial❑ Rejection Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number LC Facility's Phone: uj 18c.Signature of Alternate Facility(or Generator) Month Day Year 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 LU 1 2. 3 T 20. 1 1 Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printedfryped Name Signature Month Day Year I I I I I I I EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COP)