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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 Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST 3 "1 002'4 8.0`435 JJK 5.Generator's Name and MailingAddress Gap�ararls!,t d�lress(if different than mailing address) i , a" t� 73 A 114 17 5 10 ;(/l' Ai, I D 1,cfgjiv.:iWw-t',t,lf(-&�h4S 'I'A N, Generator's Phone: _i>1 4 1 v M44 6.Transporter I Company Name U.S.EPA ID Number .4, 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number (UmmA' " W$1,01 152'A 01J Sk"11fir R"Mil httki'mw(�'Wv,CA V0-A'W, ) 11 J Facility's Phone:e 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. 1W 1. fit R37iwP)ttv, 0 N't-,t,IN 91,1 N.V,t t I:; 11, 1f T V ixo j I f Isof Wi"t hnid -spm 2. 3. 4. 14.Special Handling Instructions and Additional Information PR4 all-71 Mw 11K.",WN'll 144voilifI4, hNit.'a"J, 15. GENERATOITSIOFFEROR'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. [Gqratoes/OffArots Printedfryped Nam Sign tu Month Day Year CJ4 W i -116.International Shipments Export from U.S. Pod of entry/exit: I- FlImport to U.S. E '3 Transporter signature(for exports only): Date leaving U.S.: IX 17.Transporter Acknowledgment of Receipt of Materials, Uj 6j Tran er 1 Pri I a Name r Signature 1 Mond Day Year 0 U) Z Transporter 2 Pdnted[Typeoa- Signature 4 Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space Quantity r Ej Type El Residue ❑Partial Rejection El Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number 43 Facility's Phone: Uj 18c.Signature of Alternate Facility(or Generator) Month Day Year Z .S2 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) U) LU I 0 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 I Printed/Typed Name Signature Month Day year EFA-Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY