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Please print or type.(Form designed for use on 1e(12-pitch)typewriter.) Form Approved.OMB No.2050-D0.39 UNIFORM HAZARDOUS 1.Gdnereta ID mber 2.Page 1 of 3.Emergency Response Phone 4.Mandest Track' Number WASTE MANIFEST 016 614 316 JJK 5.Gener"s Name and Maft Mdress- s S (d d fferent than matting address) ili1MgM�w►tti.LC. 4tbW k. llBref `- L, ia US 9rA ltTer6ei - 44um Tiwvw* Clil_M t 1m 7.Transporter 2 Company Name U.S.EPA ID Number ._r t. e '6'3hi•yy;-•:.y,: b"'tdK-F,� r qc `�E"�`"-.ie� _ «.wp( r `ct:ty-'. <. LLC U.S FPAbiYyflber CMM Face s Rmwill- ga. 9b.U.S.DOT DrrsnaOM WwAd9 Pnrper Sl*ft Mare,Hazard Ctass.ID Nunbe4 10.Contamers n.Total 12 Unit 13.Waste Codes HM aid PacldV QDW Ran!)) Ne. Type Quantity WtAVD1. O 1. hh irCi�a.Hdowdous w -Am(ix nwst w Dsbfla) 1 CM z 2. LL, ra t I 3. ; ) 4. 1 ) 14.Special Handling Inshu 'ons and Additional In anon -- - --- -- - --- -- -- wow Pmptyt'P P.E 15. GENERATOWSIOFFEROWS CERTIFICATION:I hereby dedaret that the contents of this consignment are fully and acaaately described above by the proper sipping name,and are classified,packaged. marked and labuledlplacarded,and are in all felspects in proper condition for transport awwdingivaypficable international and national governmental regrAations.If export shipment and I am the Primary Exporter,I outly that the contents of h.s cons9nment conform to the terms of the attached EPAAd"wledgrtserA of Consent I certify that the waste rr mmU3bon statement iderifilled in 40 CFR 26227(a)(K I am a large quantity generator)or(b)(d I am a small quantity generator)is true. GeneratoesiUfferors Prihoedrryped Name Signature Month Day Year .� � Q� .I .J 16.Intemational SWmerds I-- ❑Impartto S. El Export from U.S. ermyj"' Z Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter AdmoMedgment of Receipt of MaWWs oWC Transporter t Paded7Typed Name ' Signature - Day Year O a QTransporter 2 Printed/Typed Name / Month y Year t- 18.Discrepancy rr,, 18a.Discrepancy Indication Space El Que El Type 1-1Residue ❑Partial Rejection u Full Rejecion Manifest Reference Number. 18b.Attemate Facility(or Generaler) U.S.EPA ID Number J U sai Facility's Phone: U, 18c.Signature of Alternate Facility(of Generator) Month Day Year I Q � z 19.Hazardous Waste Report Management Method Codes(.e.,codes for hazardous waste treatment,disposal,and recycleg systems) UO 1. 2 3 4. 20.Designated Facility Owner or Operator:Cerlificafioh of receipt of hazardous maferets covered by the manifest except as noted in Item 1 Ba PrintedlTyped Name Signature Math Day Year 1,22111 EPA Form 8700-22(Rev.3-W Previous editions an obsolete. DESIGNATED FACILITY TO GENERATOR .f