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4, 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.Mifest Tracking Number WASTE MANIFEST 613481026JJ K 5.Generator's Name and Mailing_Address Generator's Site Address(if different than mailing address) • .i• :s:s;tGi;G SFr. ... tr . . -=:,: Generator's Phone: 6.Transporter t Company Name U.S.EPA ID Number G•.P.:.!'R!+Y.lFri:yt ! •lt.nl:,:::r .. 7.Transporter 2 Company Name U.S.EPA ID Number B.Designated Facility Name and Site Address U.S.EPA ID Number FacilitysPhone: /{!, ga. 9b.U.S.DOT Description(Including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Un l HM and Packing Group(if any)) No. Type Quantity wt./Vol. 13.Waste Codes O Z 2. W 3. 4. 14,Special Hanging 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 sh#Ing name,and are dassifled,packaged, marked and labeledtplaranied,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 certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent I certify that the waste minimization statement identified In 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(f l am a small quantity generator)Is true. GeneratorslOfferoes Printedlfyped Name Signature Month Day Year R � � - I i; D-4 05 -j 16.Intemational Shipments k— ❑Import to U.S. ❑Export from U.S. Port of entrylexit Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day Year y Q Transporter 2 Printed/Typed Name Signature Month Day . .Year F- 18.Discrepancy 18a.Discrepancy Indication Space Quantity [I Type ❑Residue ❑Parts]Rejection ❑Full Rejection Manifest Reference Number. 1 Bb.Altemate Facility(or Generator) U.S.EPA ID Number J U Facility's Phone: Qw 1 Bc.Signature of Alternate Facility(or Generator) Month Day Year z y19.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.Certification of recelpt of hazardous materials covered by the manifest except as noted in Item 18a Prinled/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY