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F sprint or type.(Form designed for use on elite(1 pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of S.Frnergency Response Phone 14.Manifest Tracking Number WASTE MANIFEST i'i �; 014789140 JJ K 5.Generators Name antd MailingAddress Generators Site Address(it different than mailing address) Generators 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 ,, I U.S.EPA ID Number Facility's Phone: ga 9b.U.S.DOT Description{including Proper ShippirN Name,Hazard Class,ID Number, 10.Containers 11.Iota] 12.Unit HM and Packing Group(6 any)) 13.Waste Codes No. Type Quantity WWo1. t i O z 2 j w I 4. 3. i`___._ 14.Special Handling Instructions and Additional lnformatio 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I"y 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,!certify that the contents of this consig uient'conform to the terns of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identifi in 40 CFR 26227(a)(if I am a large quantity generator)or(b)(91 am a small quantity generator)is true. Generatoes(Offerors Pnntedlfyped Name Signature Month Day Year 016.International Shipments ❑Import to U.S. ElExport from U.S. Port ok6lexitTransporter signature(for exports only): Date leaving U.S.: W17. e, i; I'- Transporter 1 PrintedrTyped Name Signature Month Day `Year Q aTransporter 2 Printedrryped Name Signature Month 'Day Year tl' t- 18.Discrepancy 18a.Discrepancy Indication SpaceElEl Full R Quantity ❑Type ❑Residue ❑Partial Rejection ejection Manifest Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA ID Number U L Facility's Phone W 18c.Signature ofAltemate Facility(or Generator) Month Day Year a Z y19.Hazardous Waste Report Management Method Codes(i. .,codes for hazardous waste treatment,disposal,and recycling systema) 0 1. 2. T 4. 20.Designated Facility Owner or Operator Certiftcatkm of pt of hazardous materials covorgd by the manNed except as w4ed in Item 18a Printw fyped Name Signature lip Month Day Year i EPA Form 8700.72(Rev.3-05) Prevpus editions are obsollete. GENERATOR'S INITIAL COPY