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Please print or type. (Form designed for use on elite (12-pitch) typewriter.) Form Approved. OMB No. 2050-0039 1 UNIFORM HAZARDOUS 1 ,Generator ID Number 2. Page 1 of 3 Emergency Resp Phone 4 Manifest Tracking Number ( j WASTE MANIFEST r cors, cl, ,, �- � FLE ro. Generators Nemea dMailing Address Generators Site Address ( f different than Telling address) Generator's Phone Transporter 1 Oompa y Name I ) U.S. EPA ID Number 7. Transporter 2 Company Name U.S. EPA ID Number • S. Designated Facility Name and Site Address U.S. EPA ID Number r cIys Phone. a it 9b LLS. DOT Description (Including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Total 12. Unit 13. Waste Codes r[ I and Packing Group (if any)) No Type Quantity wt./Vol, 7 © 1 C Dr 1 13, ( I It I - { 1 pocial Handling Instructions and Additional Information , . . f �_ i15. GPNERATOR'S/OFFEROR'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, I, 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 Icertify that thcontents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. r I codify that the waste minimization statement dentfied In 40 CFR 26227(a) (if I am a large quanfty generator) or (b) (If I am a small quantity generator) Is true. 1 Generators/Offerors Printed/Typed Name igna ure Month Day ear ly _ 7 —� - 16. international Shipments ❑ Import to U.S. ❑ Export from U.S. Port of entrylexit: pTransporter signature (for exports only): Date leaving U.S.: 8 & 1?. I m reporter Acknowledgment of Receipt of Materials T am power 1 Printed/Typed Name ignat § Month n[h ay Year , . l y jme ir TransiI 2 Printed(Typed Name Signature Month Day Year 13. Discrepancy ' :8a Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Refection p t Manifest Reference Number: 17L_GJlernate Facility (or Generator) U.S. EPA ID Number � i 'aciliry's Phone: ez ' Sc Ggnature of Alternate Facility (or Generator) Month Day Year 19_ Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) u : 1 4. _ Decimated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted In Item 18a Pc to /Typed Name Signature Month Day Year EPA Pcrm 5700-22 (Rev. 3-p5) Previous editions are obsolete. GENERATOR'S INITIAL COPY