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0 Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 11.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number I��, j, ),j .�I y,',i 1 oorl WASTE MANIFEST V 6 822417 JJK ' -A Ily t I — 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) R;;�,Jv)Shirck Rwici oloik 0t0fV, +4 1? A11N I 1101 Z ,V- I "d '(At X', F'twl W(nlfi T� 761,"1 Generators Phone: 6.Tra porter I Company me i QvS,.,ERA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number k 441 NVasl w 14�, 'A 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. 1- 11("'- ff ('0D I'W" V Z 2. im 3. 4. 14.Special Handling Instructions and Additional Information Vr,,,)hP1= it)i'ANK040 15. GENERATOR'SlOFFEROR'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 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. Generators/Offeror's Printed/Typed Name Signature Month Day Year al 16.International Shipments F- ❑import to U.S. El Export from U.S. Port of en /exit: Transporter signature(for exports only): Date leaving U.S.: LU 17.Transporter Acknowledgment of Receipt of Materials Tran portjr Whted1TypeqA"e I Signature Month Day Year 0 Transporter 2 Printedfryped Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space El Quantity El Type 1-1 Residue El Partial Rejection F-1 Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number =3 CV L,- Facility's Phone: L0 18c.—Signature of Alternate Facility(or Generator) f Year U Z 0 US 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0Uj 1 2. 3. 4. Designated led Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a De ignat nnteds/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY