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Plea a 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 a, ,� * , J JJK 5.Generator's Name and Mailin Addr,ess4 GagraVes ress(if different than mailing address) <� .� t£ tt�r a Ad tt 1 =art � Its ;t1c 1�;t'} AM11517018 . I I''019 I TS1 I<i*rl wolth `I"% ill(12 �;uwkf rrt ,t"A ;!06 Generator's Phone: 9P . I `UJ42. 6.Transporter 1 Company Name U.S.EPA ID Number c r 4, i 7.Transporter 2 Company Name U.S.EPA ID Number B.Designated Facility Name and Site Address U.S.EPA ID Number 35151 Old t :KA8 A �':��'f� � X117 Facility's Phone Haat(.'.tt:y,C ��123� ) N59 4�efis 91 I 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.Nol. 13.Waste Codes 1. VQI N, 8,9,1 W V Y ,h-i III., MI I r`€ 10118 V O&AI widt kail 2,C)14m Z 2. u, 0 3.' 4. i i 14.Special Handling Instructions and Additional Information r ITF Vffiffl HAIVINAP, . AUAVAI w S 15. GENERATOR'S/QFFEROWS CERTIFICATION:I hereby declare that the cont nts 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 I Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. t.` I certify that the waste minimization statement identified in 40 CFR 262,t(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. G es/Offarors,Printed/Typed Na Signature f11 I Month Da J € t (27 -t 16.International Shipments ❑Import to U.S. ❑Export from U.S. Port of entry/exit: ? Transporter signature(for exports only): Date leaving U.S.: 17.Transporter Acknowledgment of Receipt of Materials Transp er 1 Printed/Typed Name Signature ,9 Month Day Year 0. ro QTransporter 2 rintedffyped Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quanti ° ty ❑Type El Residue El Partial Rejection ❑Full Rejection Manifest Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA ID Number J C9 V- Facility's Phone: W 8c.Signature of Alternate Facility(or Generator) Month Day Year Q Z N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) ® 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 Printedffyped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY