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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 14.Manffes4 Tracking Number WASTE MANIFEST g A(TKQ6113,`1 5.Generator's Name and Mailin Addgqress y 4� Ge(neratlor s SiFte Adress(ff different than mailing address) t' 11>i4.fia.4t J' 00 Efdf*,�Shik:- Cud',;, a;• 1-t,311-' Ala N 1",-0'tJ1 A 17�J ) s#'tt'<a1t; Generator's P 6e: 8 t = 4I S 01'� 6.Transporter Company Name i U.S.EPA ID Number 7.Transporter'2 Company Name O.S.EPA ID Number B.Designated Facility Name and Site Address U.S.EPA ID Number r^�$�r`.s'lt�f3 t,`•t[,, `- ;"��t pFr t�= `a_��.��k�i,r;`;'t I Facility's Phone: ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) 13.Waste Codes No. Type Quantity Wt./Vol. 1. RQ f- ;,�c1t:4 �4�. #' 1j 5!'E' S4f3f3jfe `t w Sc$i1 M 11 ha, )2 gftt L C'a 3. 4. 14.Special Handling Instructions and Additional Information wew fIxt�t °� ;1 1. W'haft I kJot,'rtftl + ' 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 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 terns of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(x)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. G ratorr}'s/Off§§Pr)r's Printed/Typed Name Signature f Month Day Year J 16.International Shipments 2 ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Transporter signature(for exports only): Date leaving U.S.: W 17.TrapfRorter Acknowledgment of Receipt of Materials F' Trans rter 1 Printed/T d Name yPe Signature W Month Day Year `?' s i , _ y . °" r dw QTransporter 2 Printedlryped Name Signature Month Day Year t- 18.Discrepancy 18a.Discrepancy Indication Space ❑ , Quantity F-1 Type ❑Residue ❑Partial Rejection ❑Full Rejection i Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J II CU W Facility's Phone: W 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) O 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