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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 4. Manifest Tracking Number WASTE MANIFEST _ _ FLE 5. Generators Name and Mailing Address Generator's Site Address (if different than mailing address) m Kirtle Ar ?f fi. iT l'GB R?O kYi USti [ GFIn 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 U.S. EPA ID Number Facility's Phone: - ga gb 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 VAN& O Q z 2. LJ C7 3, 4. 1 14. Special Handling Instructions and Additional Information _ 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 Iabeledlplacarded, 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 Partly that the contents of this consignment canton to the terms of the attached EPA Acknowledgment of Consent. I catty that the waste minimization statement Identified in 40 CFR 262.27(a) (if t am a large quantity generator) or (b) (if l am a small quantity generator) is true. ' Generator's umerors notmeal Typed Name signaturas Month Day 715ar 16. International Shipments - z ❑ Import to U.S. ❑ Export from U.S. Port of sntrylexit: Transporter signature (far exports only): Dale leaving U.S.: w 17. TmnsporterAcknowledgment of Receipt of Materials Transported Printed/Typed Name ignaturent sy ear O I I I a z Transporter PrintedF-yped Name Signature Month Day Year F 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Portal Rejection El Full Rejection Manifest Reference Number: F 18b. Alternate Facility (or Generator) U.S. EPA ID Number U Q LL Facill 's Phone: du 18c. Signature ofAltemate Facility (or Generator) Month Day Year Q z (7 N 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 0 1 . 2. 3. 4. 20. Designated Facility Owner or Operator: Certficatien of receipt of hazardous materials covered by the manifest except as noted In Item 18a PrintedlTyped Name Signature Month Day Year EPA Form 6700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY