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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 -F Manifest Tracking Number WASTE MANIFEST 1i I&F -Ml I I 1 00 82441 JA 5.Generators Name and Mailing Address Genera oes Site Ad ress(d different than mailing address) 0*,'!Vipl -Clrd,tdN T4 i"t AJ Itl f 7' I io I N A I tiI . I ,`§j Fkoi �Vivs-fh T ' I 11fr" *,,Moii ij 1`0 Generators Phone: 3 1 6.Trans rter I Compan gtrta U111DNumbs A 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number 352"4 Old Styiikw Rt?�O it,4 I k 11%j,(,'A 4%6,44111 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(N any)) No. Type Quantity Wt./Vol. *'j N i, ILI 0q)IJ With It"t.) 21a0 jq);o) L 3. 4. 14.Special Handling Instructions and Additional Information Wrew hfqwt 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 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. n" ratoes/ eroes Printecirryped Name Signature " Month Day Year If i I 1 4 TT W !J; -j 16.International Shipments L' 0 17 Elimport to U.S. El Export from U.S. Port of entry/exit: Transporter signature(for exports only): Date leaving U.S.: W L 17.Transporter orter Acknowledgment of Receipt of Materials :2 rrted� pe amen Signature I �-I* Month, Day ay Year_ 0 0. 1 .4 ca 6'T Z Transporter 2 PrIntedrryped Name Signature Month Day Year W 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity El Type El Residue ❑Partial Rejection El Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number Facility's Phone: C3 1 j Lu 18c.Signature of Alternate Facility(or Generator) Month Day Year Z 05CD 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) Uj9. 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 PrintedlTyped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY