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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 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST f; �°ffs' t ;' 00 Is 15 JJK 5.Generator's Name and Mailing Address Generator's ?Mss(if different than mailing address) APf'J )'01 if,)JX& 1 71'a11 014 sus,, $ . trr tj r;71€°@ . E ftp !A'0;;'Jvvi§ € 3 �1N 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 g fasff�kJarloy S� xj ("Ad, s aS't#st I'Zowl e tk'1 out 4 G#tR.CA¢,.QA.') "a,W 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./Vol. W I. 't'e A,. 'fit$�8e t..iC1",�ttgS t ?� s».:',#344 '" t:zs`s4 6;"f $$4'R$'s< 4'1441 011 tskaj With f Z 2. LU C9 3. 4. 14.Special Handling Instructions and Additional Information a' ,s # e f :r )'1)1° e ')t t+liof-)tntf� hilwk 1m) '. 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)(ff I am a small quantity generator)is true. GeMratoes/Otteror's Printed/Typed Name Signature Month Day Year =j 16.Intemational Shipments El Import to U.S. ❑Export from U.S. Port of®ntry/exit: z Transporter signature(for exports only): Datelaiving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials 7 Transpoffer;l PnntedlTypeamert m• Signature. ' r :` Mcc ggfkv Day Year ZZ Transporter 2 Printedfryped Name Signature Month Day Year t- 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Typej j ❑Residue ❑Partial Re ection El Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J Z3 u`.. Facility's Phone: tuu 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z y19.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 PrintedlTyped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL C I I