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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 A(,1XV6 2 13'11 002182424 JJK- 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) 4. 7+I A, A Generators Phone: A I S, U142 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 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 Quanfity Wt.Nol. 1. 0 11 N41!71,11:'3 Ill, (104 U1, IX 9 i I y UUj j MA IWO IVs ?70 0) ;14; Z 2. Uj 3. 4. L 14.Special Handling Instructions and Additional Information fltfki. a)"A W? 84J wm,11ti-tigm F11,11, 15. GENERATOR'SIOFFEROR'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)(ff I am a large quantity generator)or(b)(if I am a small quantity generator)is true. L [Gie;n7eratoestOfferors Prine'ted/Typed,Name Signature Month Day Year- t - F13 l i i L R , i -1 1 16.International Shipments Z 1:1 Import to U.S. ❑Export from U.S. Pod of entry/exit: 9 Transporter signature(for exports only): Date leaving U.S.: IX 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printecirryped Name Signature I J Month Day Year 0 0. L U) Z Transporter 2 PrIntedfry NameSignature /7- Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity, 1-1 Type F-1 Residue ElPartial Rjecfi.r, ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number W Facility's Phone: 0 LU 18c.Signature of Aftemate Facility(or Generator) Month Day Year !R Z 55(D 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 LU 1 2. 3. 4. 20.Designated Facility,Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Rem 18a Printedrryped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY