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I 'r Please print or type.(Form designed for use on elft (12-pitch)typewriter.) 1.Generator ID Nu ber Form Approved.OMB No.2050-0039 FUNIFORMARDOUS 2 Page 1 of 3.Emergency Response Phone 4,Manliest Tracikinq Number IFEST i �,,� � JJK me and Mailing Address �" E Generator's Site Address(if different than mailing address) rI(wl*"ie4lMlt*N(.I.(. 9:l't Generator's Phone: ° .C A 911'itZ l 6.Transporter 1 Company Name U.S.EPA ID Number 7 Transporter 2 Company Name U.S EPA ID Number -111113-V 8.Designated Facility Name and Site Address U.S.EPA ID Number lig IrWXIik'. i;�dif,�(!wgi�ier i 1.� 1ti'ast LAken)Rd t A[�fi[1flSZld Hit MC fTw^)w.(.A 0*42()lt) Facility's Phone: ga 9b.U.S DOT Desaiption(including Proper Sh pping Name,Hazard Class,ID Number. t0.Containers HM and Packing Group(if any)) 11.Total 12.Unit No, Type Quantity Wt.Nol. f 3 Waste Codes 0 1' "(?iS 1 IM'-WriPA14 VVVj--,4§j syokll{F t�, v c- r (try } LU Z 2 LU t9 3 r 4. 14.Special Handling Instructions and Additional Informs ion 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I vreby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labeledlplacarded+and are in all rmswsin 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 the consignmi trit conform to the terns of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement Iden ed in 40 CFR 262.27(a)(If I am a large quantity generator)or(b)lift am a small quantity generator)is true. Generators/Offerors PrintedrTyped Name Signature Month Day Year -j 16,International Shipments Z ❑Import to U.S. ❑Export from U S. Porgy of entry/exit Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials = Transporter 1 PnntedTyped Name Signature Month Day Year a QTransporter 2 Pnnted'Typed Name Sig aturer Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space Quantity Type ❑Residue ❑Partial Rejection ❑Full Rejection 18b.Alternate Facility(or Generator) Manifest Reference Number: U.S.EPA ID Number J U LL Facilrtys Phone: w 18c.Signature of Altermate Facility(or Generator] Month Day Vear Q z 6, 19 Hazardous Waste Report Management Method Codes .e.,codes for hazardous waste treatment,disposal,and recycling systems) LU t 2. 3. 4. - I f 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted In Item 18a PrntedTyped Name Signature > Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obs tete. ' TRANSPORTER'S COPY