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Please print or type. (Form designed for use on elite (12•pitch) typewriter.) Form Approved, OMB No. 2050.0039 UNIFORM HAZARDOUS1- Generator ID Number 2• Page of 3, Emergency Response Phone 4. Manifest Tracking Number WASTE MANIF ( �[1V I\ S 5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) Generators Phone: 6. Transporier,lCompanyt (ame _, . F, . .. ic . ' rt,, U.S. EPA 1D Number , •,. .; i, ,.rr_a _ ;^` ` it 7. Transporter 2 Company Name U.S. EPA ID Number 8, Designated Facility Name and Site Address ( ' • •r ' � r — ', i, LJ r'. . a : .it : ..) '. ,.t :. . . It f iIHWSl .,t {JII:] 1:.. 1 , i ..f ,'.� �.' .`• .. .. ',. Facility's Phone: ;; 'L<i,' ga- 9b. 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 Wt.Nol. = 1 . t�l - u � `_ r: t,., , tY ' .f`{. � = : f.. TP 4,. . 1y t ' r•.' :J - 7 .Z ' v Z 2. trs 0 3. 4. 14. Special Handling Instructions and Additional Information II .li f..i ." - - i'r•� . � . <+Li • At Mr t ' :. i, r .. f. . . 7 -^• it t '` f'. ri.�r.' - i i.'.`r'4 I 1. ,, 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, 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 Pdmary Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowiedgment of Consent. I certify that the waste minlmizallon statement Identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if t am a small quantitygerieralor) is true. Generators/Offerors PrinledrTyped Name Signature Month Day Year —r 16. International Shipments F ❑ Import to U.S. ❑ Export from U.S. Pod of entry/exit: Z Transporter signature (for exports only): Date leaving U.S.: 17. TranspoderAcknowledgment of Receipt of Materials fi�, Transporler 1 Printed/Typed. Name Signature Month Day Year co JI I Transporter 2 PrinledlTyped Name Signature Month Day Year W t- 18. Discrepancy 18a, Discrepancy Indication Space Quantity ❑ Type yp El Residue El Partial Rejection El Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number �.r c� tai.. Facility's Phone: ow 18c. Signature of Alternate Facility (or Generator) Month Day Year -a z 55 19, Hazardous Waste Report Management Method Codes (Le., codes for hazardous waste treatment, disposal, and recycling systems) 0 4. 20. Designated Facility Owner or Operator: Cedificalion of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year .PA Form 8700,:22, (Rev. 3-05) Previous editions are obsolete. GENERATOR 'S INITIAL COPY