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Please pint or lyoe (Poem des:gned for use on elite (12-pitch) typewrites`_i Form Approved, OMB No. 2050-0039 UNIFORM HAZARDOUS 1 Generator ID Number 2.Page 1 of 3 Emergency Response Phone 4. Manifest Tracking Number WASTE MANIFEST Generatnr'S Nanr>�tnd Mai.ing Aldrass Generator's Site Address fit differont than mailing address) Phone r T ramt iter 1 :°;orn tar,y gams US EPA ID Nlumbar Tramhoder 2 Coinr.any Name tltl US EPA ID Number I 8 Designated Facility Name and Site Address US EPA ID Number Facility s Phone. ga, 9b U.S DOT Description(including Proper Shipping Name,Hazard Class, ID Number, 10 Containers 11 Total 12 Unit 13 Waste Codes HM and Packing Group(if any)) No Type Quantity Wt Not O z 2 w t9 3 I td ;pualHandlrnr`In»rafogs,YnriAd�li„onalfnform.rliorr I 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 EPA Acknowledgment of Consent I certify that the waste minimization statement identified in 40 CFR 262 27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is he. Generators/Offerors PrintedfTyped Name Signature Month Day ear 16 International Shipments H ❑Import to U S ❑Export from U S Port of entrylexit: z — Transporter signature(for exports only): Date leaving U.S w 17 Transporter Acknowledgment of Receipt of Materials Transporter 1 PrintedfTyped Name Signature Month Day ( Year [L ( I I QTransporter 2 Printed/Typed Name Signature Month Day Year I a 18 Discrepancy 18a Discrepancy Indication Space ❑ Quantity Type ) j❑T e ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b Alternate Facility(or Generator) US EPA ID Number _J V LL Facility's Phone: W 18c Signature of Alternate Facility(or Generator) Month Day Year Q z 19 Hazardous Waste Report Management Method Codes(i e,codes for hazardous waste treatment,disposal,and recycling systems) { 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 P+nb dTy�rd Name 3igrature Month Day Ya_er EPA Form 8700-22 (Rev 3 05) Previous editions are obsolete. GENERATOR'S INITIAL COPY