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;e print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 1 Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number UNIFORM HAZARDOUS 0+-! n A 7 C t1/11 A I WASTE MANIFEST 5.Generators Name and Mailing Add Generators Site Address(if ifferenI than maik address) G�lr�,�wj''';;r�fi '��.' 416 Generators Phone: 6.Transporter 1 Compan Name t U.S.EPA ID Number _ 7.TransWer 2 Company Nlirne U.S EPA ID Number t 8.Designated Facilik Name and Site Address U.S.EPA ID Number S06 hU� f(!r j�rC�//ur %D�� Facility's Phone: z --- o o r ga 9b.U.S.DOT Description(including Proper Shipping 16 me,Hazard Class,ID Number, 10.Containers 11,Total 12.Unit and Packing Group(if an Quantic Wt.Nol. 13.Waste Codes HM 9 P Y)) No. Type Y f 2. 3. } - 4 4. 14.Special Handling Iniad ns and Additional Information_ .5,C r f. _ r(.. CN v 4A 15. GENERATOR'SIOFFEROR'S f gRTIFICATION: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 andlabeled/placded,and are in all respects in p oper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the PrimaryExporter,I certify that th contents of this consignment cor form to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in Q CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true 3eneralors/Oflerors Pdnted/Typed Name Signature }' Month Day Year I6.Interna nal Shipments t ❑Import to U.S ❑Export from U.S.'' Pori of entry/exit Transporter signature(for exports only): Date leaving U.S.: 17.Transporter Acknowledgment of Receipt of Materials -ransporter 1 Printecirryped Name Signature Month Day Year rransporter 2 Printed/Typed Name ` Sigoure ! Month Day Year j� 18.Discrepancy Ba.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Portia Rejection ❑Full Rejection Manifest Reference Number: i8b.Alternate Facility(or Generator) U.S.EPA ID Number :acility's Phone: 8c.Signature of Alternate Facility(or Generator) Month Day Year 9.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 2. 3. 4. I '.0.Designal a"`Owner or Operator.Certification of r' i t of hazardous materials covered by the manifest except as noted in Item 18a xr nted/Typ Signature Month Day Y =orm 8700-22(Rev.3-05) Previous editions are obsol DESIGNATED FACILITY TO GENERATOR