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tease print ar type.(Form designed for use on elite(12-titch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS y-Genersior ID Number 2 Page I of 3.Emergency Response Phone T4.61anifest Tracking Number TWASTE MANIFEST �( �,�)(_C.11(.,:)�—:) Z_.� I ;.r < `,�1, ci; ,tr 1) ` 1 JA ne(ator's Name and Mating Address Generators Site Address(d ddferent than ma ng address) Generators Phone: 6;Transporter 1 Company rlame U.S.EPA ID Number , 7.Transporter 2 Company Nama U.S.EPA ID Number 8.Designated Facility Name apd Site Address U.S.EPA ID Number FaGlit's Phone: 1 "It) ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HCI and Packing Croup(it any)) No. Type Quantity wt/Vol. I. '� ( � (.'1. .�Jf.-.1,-., ra.•_rTAn It 1 i - tfqS BEN LU 2. FOR RECICLING/TREATMENT AT THE LIFIED ^0.'MENNOII(ERDOON Oil iTV JAI 3. THIS FiY HAS THE NECESSARY PERMITS TO REG'EIVE YOU WASTE ST Q 4, IS GAT080013ag52 pecial Handling Instructions and Additional Information I. 1 t'L•.IT,EAN 15 GEN ERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of Ws consignment are fully and accurately described above by the proper shipping name,and ere classified,packaged, marred and labe!ed/placarded,and are in a'I respects in proper condition for transport according to applicable international and national governmental regulations.It export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAckw,,.ledgrnenl 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)(if I am a small quantity generator)is true. Ge nerator'slOfferor's rinledrT ped Name Signa re Month Day Year _.r 16 International WpmerO ❑Import to U.S. ❑Export from U.S. Potl'o enlrylexd: Transporter signature(for exports only): ate aving U.S.: W 17 TranspoderAckna,IedgmentofRecefptoft.laterias �2 Transporter 1 PrintedrTyped Name Signature Month Day Year O Z Transporter 2 Printed(ryped Name Signature Month Day Year a H 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Part-al Rejection ❑1`0 Rejection Manifest Reference Number: __. 18b.Alternate Facility(or Generator) U.S.EPA 10 Number ' J U lu Facility's Phone. w 18c.Signature of Alternate Facility(or Generator) f'onlh Day Year a11 z iazardous Waste Reppit Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) / 3. 4. 20.Designat�d Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest exce i as noted in Item 18a PrintedrTyped';Yame S:gnaturgI Month I Day Year EPA Form 8700.22(Rev.3.05) Previous editions are obsolete. UESIGNATkD FACILITYTO GENERATOII