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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 002182425 JJr%- 5.Generators Name and Mailing Address Generators Site Address(ff different than mailing address) X) Kwbo 'fly V h-1 c I-A V, N f?",1'0 18 Ak I 1 0 1 6"" 1 1 Vft�i WtOjt- 'I'X 7f"'1 A 0'00� Generators Phone: a fl I1 A04 1 6.Transporter 1 Company Name U.S.EPA ID Number + 7.Transporter 2 Company Name U.S.EPA ID Number B.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 Quantity Wt./Vol. 44,11,4410 1"(i fit I 1 11 V 3. 4. 14.Special Handling Instructions and Additional Information tla r Il,P at 4 i,"AY-XYM0 wew 14111, V11f.)4 I hal4ftol! 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 intemational 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)(if I am a small quantity generator)is true. Generator's/Offeror's Pdntedrryped Name Signature Month Day Year o7 (i r�iz'o .4 16.International Shipments E❑import to U.S. ❑Export from U.S. Port of entry/exit: Transporter signature(for exports only): Date leaving U.S.: UA 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printednyped Name Signature Month Day Year 7 0 IL U) Q Transporter 2 Printedirryped Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space F] Quantity a El Type El Residue 0 Partial Rejection El Full Rejection I I Manifest Reference Number: 18b.Aftemate Facility(or Generator) U.S.EPA ID Number Facility',Phone: Uj 18c.Signature of Alternate Facility(or Generator) Month Day Year !Q Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 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 Item 1 as Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY