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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 r� -f ' 2429 JJK I WA,026`13 1 0 0 4 1 5.Generator's Name and Mailin ddress Generators Se Address(If different than mailing address) 1,wlqre Jowl.i vfvk' &I'S 1,.1.,,1..' 'A 111' 1 !S 1 8 A 1 101 1 1 Generator's Phone: 48 1'.1! 1 i r31 t1 2 6.Transporter 1 CompanyaName U.S.EPA ID Number k 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number Ow"ti(vI ww& :i5lllil Old R�*dl Al f A 004,t6 I I h.00k,twif I i.V 'A 40 1 i Facility's Phone: 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) No. Type Quantity Wt./Vol. 13.Waste Codes fY N i")S,9�2 1 IMAY"",hi 'k'III 1-0, a )t I I 1� LU Z 2. LU CD 3. 4. 14.Special Handling Instructions and Additional Information wf'#'f L/ 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)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generators/Offerors Printed/Typed Nam P Signature Month Day Year �j 16.International Shipments M Import to U.S. El Export from U.S. Port of entry/exit: Transporter signature(for exports only): Date leaving U.S.: Be 17 Transporter Acknowledgment of Receipt of Materials U 12 TranAporter I Printed/Typed Nq= Signature Month Day Year 0 1 Z Transporter 2 Printed[Typed Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Spacer Quantity Type ❑Residue El Partial RRejectionEl Full Rejection El I Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number Facility's Phone: T8c.—Signature of Alternate Facility(or Generator) LU Year tR Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) Uj 1 2. 77 4. — In ed Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. I I I I GENERATOR'S INITIAL COPY