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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 . Generator ID Number 2. Page 1 of 3. Emergency Response Phone 6. Manifest Tracking Number WASTE MANIFEST r . - _ . . LC FI C 5G@ns?N eratorame and Mailing Ad s - - Generator's Site Address ( f different than coalin11 g address) Emil ESP L'-L ppIJ7MMGK- MYvYN3D ShllRLF111�91�11Of1MRplLiC�Fn G"e area hon , -1`w II 8, 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 Facillty's Phone: ur 92. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class. ID Number. 10. Containers 11 . Total 12. Unit HM and Packing Group (If any)) No. Type Quantity Wt./VO[. 13. Waste Codes up 2 w 0 3, 4. 14 Special Handling Instructions and Additional Information t. DIM10 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents This consignment are fully and accurately described above by the propershipping name, and are classified, packaged, marked and labeledleacarded, 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 oddly that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. certify Ihat the w este minimization statement identified in 40 CPR 262.27(a) (if I am a largequantity generator) or(b). (if I am a small quantity generator) is true. Generator'sluterors PrintedlTyped,Name tgnature ont ay ear 116. International Shipments z ❑ Impartto U.S. ❑ Expel from U.S. ' Port of entry/exit Transporter signature (for exports only): Date leaving U.S.: w 17. 1 ransporterAcknowledgment of Receipt of Materials mansponerl Printed/Typed Name Signature Month Day Year L aTransporter 2 PnntediTyped Name Signature Month Day Year r - T18, Discrepancy 10a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: F 10b. Alternate Facility (or Generator) U.S. EPA ID Number :JI U Q u- Facility's Phone: w 18c. Signature of Alternate Facility (or Generator) Month Day Year ZZ 19. Hazardous Waste Report Management Method Codes ('.e., codes for hazardous waste treatment, disposal, and recycling systems) 20 Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Prnted7yped Name Signature Month Day Year - EPA Form 8700-22 (Rev. 3-05) Previous editions are cbsoletg .,y DESIGNATED FACILITY TO GENERATOR