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Please, print or type. (Form designed for use on elite (12-pitch) typewriter.) Form Approved. OMB No. 2050-0039 UNIFORM HAZARDOUS 1 1 . Generator ID Number 2. Page 1 .of3. Emergency Response Phone 4. Manif11925638 estTracking_Nupber. 'WASTE MANIFEST rC Q 1 9 �ry�+1l 5 6 3 8 FLE . 5. Generamr's Name and Mailing Address Generator's Site Address (a different than mailing address) L h;wtisT shlxti. iYethepVfht�lfusp,cam ceneramrs Phone: :- 6. Trarsponer 1 Company Name U.S. EPA ID Number i 7. Transporter Company Name U.S. EPA ID Number B. Designated Facility Name and Site Address U.S. EPA ID Number PSC e . M E 1 4 23a)`XW U ii:i; 'i 'd AYi63 u �caQl:''j Facility's Phone: 775.6:'+3•,22t7: *' ge 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 1t . Total 12, Unit 13. Waste Codes HM and Packing Group (if any)) No. Type Quantity � WtNol. Aijan 3CCRA HAzvilini ; 4Y-Me Sold (Cma ked Mehl Paint CM 1L1�eNs & dam '. - w Z z. ED ED3 4. 14. Special Handling Instructions and Additional Information F N111mbor ll DMOlmwo k. Mil 1) EAM33; 0702171160 ORt1 J i n C 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, rnarkeoandJabeledtplacarded._aadareiin.all.respebts4nproper-condition for-transportecwrding-to'-applimMenternational antrnetionaFgavernmental-regulations. F ezportshipment andl'amthe PrIfir -- - Exporter, I certify that the contents of this consignment conform to the terms of the crashed EPAAcknowledgment 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 true. - GeneratorslOffenors Printed/Typetl Name blignature Month Day Year �j 16. International Shipmeff Z Import to U.S. ❑ Export from U.S. Port of entrylexit: Transporter signature for expels only): pate leaving U.S.: W 17. Transporter Acknowledgment of Receipt of Materials Transporter l Printed/Typed Name ignatur ,r, Monthub ay Year Transporter2 Printed/Typed Name Sgnaiture Month Day Year K H 16. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type yp El Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number, F 186. Alternate Facility (or Generator) U.S. EPA ID Number d ' LL Facili 's Phone: - - _- - ' - - -- - -W 1So. Signature ofAltemate Facility (or Generator) Month Day Year Q z 19, Hazardous Waste Report Management Method Codes f e., codes for hazardous waste treatment, disposal, and recycling systems) JUL[ 1 n 1 2. 3. 4. o 20. Designated Facility Owneror Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 188 nntedRyped Name Signature Month Day Year EPA Form 3700-22 (Rev. 3-05) Previous editions are obsolete. - DESIGNATED FACILITY TO GENERATOR