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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 Number2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number If WASTE MANIFEST ;^, f,`tftt,?f} 10 j 1 0021 82421 JJF% 5.Generator's Name and Mailin Address Generator's Site Adress(ff different than mailing address) @. g py & { A1'N x 3aa6 p n tIt2ko PVI' 4,�§`4 1" i'�i,1'N 1 ?51 t 4�.�Pt`'.$� L t ,1�#'?:'�$ Niim,tt,it Generator's Phone: k S ' 1 `s _1s a. ' 6.Trensportg�i Co pany Name a r` f t 1 U.S EPA Ij)NurOber °. 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number ° r7€'ffs: t wts->.f '$ttt);:1rert€t ._:'e$ (.sa1a4"vh!�c V 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. ® f10S $� ai€f4'43l �" IN III fts"I ?1' t'�XIIs+ ' fS(T11 with Z 2. W 3. 4. 14.Special Handling Instructions and Additional Information Pfciteu I of°`"s 't- fi Pa ra-1 Pil!' VOwIt I1a°ttt4tvi 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 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. Grator's/Offgror's Printed/Typed Name Signature Month Day Year t s t) l i ojcS { 'a �? #: I`i ' t' / J 16.International Shipments ❑Import to U.S. ❑ try i- Export from U.S. Port of en /exit: Z Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Transporter0rintepI/Typed Name g Signature t` Mori I3s a Year CL aTransporter 2 Printedfryped Name Signa.... Month Day Year t- 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residuej EI Full Rejection ❑Partial Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J � V ua- Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year Q 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) ® 1. 2. 3. 4. I 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 Y