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Please print or type. (Form designed for use on elite (12-pitch) typewriter.) Form Approved. OMB No. 2050-0039 F UNIFORM HAZARDOUS1 . G nerator ID Number 2. Page 1 of 3 Emergency Response Phone 4 Mar21nifest Tracking Numbe Y'dASTE MANIFEST114 4 r FLE 6 Generators Name and Mating Address Generators Sire Address it diHarent Man mailing address) j tlGenerator's Phone ` = ; k4 _ Transporter 1 Company Name � U.S. EPA ID Number 7. Transporter 2 Company Name U.S. EPA ID Number iI 8. Designated Facility Name and Site Address U.S. EPA ID Number � I S Facill tys Phone tit ga Nb U.S, DOT Description (i cl d ng Proper Sh pp ng Name HazardClass, ID Number 10. Containers 11 . Total 12 Unit Nand Packing Group ( f any)) 13. Waste Codes u N I � No. Type Quaritty WLNoI. r - - _ it lz Iy2 .. P D S i , li 14 Speoel Handling Ituctons and Additional Information 15. GENERATOR'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 classill packaged, r 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 f I Exporter l certfy that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. 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. Ce £ tors/Offero Printed/Typed Name Signature Month by ear I _� MmaHonel Shipments - ❑ ImporttoUS. ❑ Export from U.S. Port of entry/exit: Tr nor±ersnature (for ex onson Y) Date leaving U.S.: 17. Transporter Acknowledgment of Receipt of Materials I— I ransterther i Pr nledtTypetl Name I Signature; t Mont ay Year � Vc iTr,nspotar2 Pr'rned/Typed Name 'Signature Month Day Year cre 15. Discrepancy 18a.a . Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: I ! 18b. Alternate Facility (or Generator) U.S. EPA ID Number ��— Fzcilitv's Phone: 1 � 16c- Signature of Alternate Factry (or Generator) Month Day Year Vz Ao 910. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) cD 1 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 PrintediTyped Name Signature Month Day Year EPA Form. 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY