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Pleqse 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 I C.A(1XV102 1 S7) 1 002.1` 82451 JJ 5.Generator's Name and MailingAddress Geparate �t s Adfress(if different than mailing address) wlfi,�"4kAA W 301 Kad: 'Shack k, 01,, ik�9,:(1-4 32 A P N I 7,'t I 7V I I i,?1'11())1 1 f.,1 Nfio,4-Vw 'A Q%206 Generator's Phone: 6.Transporter 1 Company Name U.S.EPA ID Number Al le A ;AC-,e 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number (1r-mi(ml Wkwfe K C-0-k4 10 1 if#C44 V A 91A?,V `s V,% 114 Q 111 Facility's Phone: 9a, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers It.Total 12.Unit HM and Packing Group(if any)) No. Type Quantity Wt.Nal. 13.Waste Codes 1. RQ, fW-rajdc"V,N101 40 (Ot 0 f,.j -us,Q,11 INMV/7,K+III, N)I IYV [KK)11-1 Oka?with Ifmd22ho 4ymi L 3. 4. O 3,- 14.Special Handling instructions and Additional Information I-If i kflh-,,f1i it)('A,W0290 "0171 Wcar Pusfw� 1114,' Z 15. GENERATOR'SlOFFEROR'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. GeneratoestOfferoes Printedfryped Name Signature Month Day Year NB � GfVf RAT �0 lit U -- -r�) AGor, fi�g, I 1 24 b 14>7 -1 16.International Shipments I- - R import to U.S. El Export from U.S. Port of entry/exit: 9 Transporter signature(for exports only): Date leaving U.S.: U% 17.Transporter Acknowledgment of Receipt of Materials E Transporter I 0 Tra�� ,;1, ntedrryped Name Signatu Month Day Year CL r IX Lille t - I I �f !�2 Transporter 2 Printedfryped Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space Ouantity E]Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: I= 18b.Alternate Facility(or Generator) U.S.EPA ID Number :3 LA- Facilitys Phone: U0 18c.Signature of Alternate Facility(or Generator) Month Day Year 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LU 1. 2. 0 4. FDesignated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a ,gy�te rin Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY