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Pleas-p,i,it or type.(Farm 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 Trac1014783200 kiing NumberrrWASTE MANIEST ! .! s "{' ' �" J�1K 5 Generator's Name and Mailing Address Generator's Site Address(Ydifferent than mailing address) Generator's Phone 6 Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8,Designated Facility Name and Site Address U.S.EPA Ip Number r Facility's Phone 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)) 13.Waste Codes No. Type Quantity Wt.Nof. G i # Z 2LU a C7 i i 3 4 i 4 P 14 Special Handling Instructions and Additional Information .. r 15 GENERATOR'SIOFFEROR'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 EPAAckrowledgment of Consent. I certify that the waste minimization statement identffed in 40 CFR 262-27(a)(if I am a large quantity generator)or(b)('d I am a small quantity generator)is true. GeneratceslOfferor's PdntediTyped Name Signature t - Month Day Year J 16 international Shipments a Z11Importto U S EJ Export from U.S. Port of enlrylexd. Transporter signature(for exports only) Date leaving U.S.. LW 17 TransporterAcknowledgment of Receipt of Materials C Trensporter,lr Signature ,Ponledff ped Name Month Day Year CL r f Z Transporter Printedllyped'Niame Signature Month Day Year 18 Discrepancy 18a Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b,Altemate Facility(or Generator) U.S.EPA ID Number J_ V Facility.Phone- 1 Bc honeLi 18c Signature of Alternate Fac lily(or Generator) Month Day Year Z a 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LU p 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 Printedlfyped Name Signature Month Day Year EPA Form 8700 22(Rev.3-05) Previous editions are obsolete GENERATOR'S INITIAL COPY