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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 1.Generator ID Number Emergency Response Manifest Tracking Number WASTE MANIFEST IC A f XX061 I V1 j 002182422 JJK 5.Generators Name and Mailing Address Generators Site Address(If different than mailing address) po4" AVI-4 I 7-S J'AtIR I "'Sl �019;L Generators Phone: 6.Transporter I Company Name U.S.EPA ID Number 7.Tran porter 2 Company Name U.S.EPAIDN(IMbdir 8.Designated Facility Name and Site Address U.S.EPA ID Number qtfivA wak"If, 'Jjy, A (13,?I V, 4Y4 UM 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(9 any)) No. Type Quantity Wt.Nol. 1. KQ 0 (Nil With 1 1 1,2f,iqlm) Z 2. LU 3. 14.Special Handling Instructions and Additional Information gg 0I'll 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 intemallonal and national governmental regulations.11'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. Generatoes/Offeroes Printed/Typed Name Signature Month Day Year I t-)IIii (-I At"-, 0 IAL )�I' _j 16.Intemational Shipments Import to U.S. D Export from U.S. Port of entry/exit: Transporter signature(for exports only): Date leaving U.S.: LU 17.Transporter Acknowledgment of Receipt of Materials 1E Transporter 1 Printedrryped Name Signature Month Day Year 0 rtdr r2 Pflnted/Typed Name Signature Month Day FF 7 1 1 1 1- 1 I18.Discrepancy 18a,Discrepancy Indication Space El Quantity El Type ❑Residue F-]P,rtl,l❑ Rj,cfion 0 Full❑ Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number LL. Fcilitys Phone: C3 LU 18c.Signature of Altemate Facility(or Generator) Month Day Year tR Z a 55 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) Uj 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