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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2060-0039 UNIFORM HAZARDOUS '-Generator ID Number 2.Page I of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST 4 tL ',AC(Kk 671Y'71 00f) 82465 JJK_ 5.Generator's Name and Mailing Address Gaper oes S e A ress(If different than mailing address) _VX"R.-44l Sfh*(4,'('ItOc M,';(,'P4,31 A04 )Ttot_101 9& 1751 !Oil)& 1 7�1 F4 o t W4)oft a TY, 16 10 h Generators Phone: h,11 15 Y142 6.Transporter I Company Name U.S.EPA ID Number 21 4, 1".i 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number Chmnit"A W,1'4!(' 'VQ11 A �l ( d SVyhw,-Kiwi4.:AJ1 VXU00 I I? KfAfltmumi C*,�,('A 93239 Facility's Phone: 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. 1 Efivii-olinum 1W (Aly 11Wzot4h'"_t',S10WLwtQVA,NAW til I 0 N f)IK� ,Q,I IN'Y)77.Ilk,fit, I 10 (,SAW With IV4270 11,#m) L to 1 3. 4. 14.Special Handling Instructions and Additional Information 'AR_W'i8R wcmv 1,114-01wt,Pill;,Wh*4t limidbit'g,mateum 15. GENERATOR'S/OFFEROR'SCER71FICATION: 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 consig*ent 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. Generator's/ eror's Printed/Typed ame Signature W 11� 6� NIT F-R G-f Of Month Day Year +1 ILL -z- 09 9 _j 1 16.International Shipments E]Import to U.S. ElExport from U.S. Port of entrylexit: Z Transporter signature(for exports only): Date leaving U.S.: Ot 17.Transporter Acknowledgment of Receipt of Materials W Transporter I Printedlrypad Name Signature Month Day Year 0 o. AL- 1 "", - ca L_ -------- -7 1 I i _-A Transporter 2 Printedrryped Name Signature Month Day Year: 18.Discrepancy 18a.Discrepancy Indication Space 1:1 Q'uanUty E]Type El Residue El Partial Rejection El Full Rejection Manifest Reference Number: 18b.Aftemate Facility(or Generator) U.S.EPA ID Number CU Facility.Phone: LLj 18c.Signature of Aftemate Facility(or Generator) Year Zth Day-7n1 1 0 V5 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0Uj 1. 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 EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY