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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 FJUNIFORM HAZARDOUS 1.Generator ID Number : 2.Page 1 of 3.Emergency Response Phone MMan5estTr kiw,Number WASTE MANIFEST +at new► u�rry iS^r at + d •Fi w r D FLE 5.Generator's Name and Mailing Addr s"' "" ` Genetatite Address(if ifferenl than mailing address) ICt 1Ek P� rr t•rr :a u -3725 N Tr;sBlvd Generator's Phone: 1J 6. ransporter 1 ompany Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number fu;titvw{��5,i l titit4a{�tfsrtrltr<s1 E1+s�y Facility's Phone: l cwtu&I,d" 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) 13.Waste•Gbde"s No. Type Quantity Wt.Nol. 1. o .0. .,1, PO to Jw c'. r "Wer) Z 2. LU Y�;f,�t�&€;� ��:��rn��a•`�ra�t� o:�r„'e1 7 ' � j ''1 3 �. . :. 4. II 14.Special Handling Instructions 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 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 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)(if I am a small quantity generator)is true. Generator eror'sPrinted/Typed Name signature , _ on ay Year cZ\Y 1 C\ C I r`r `. " -r,�a. �1�.-�.�t7 t f _+ 116.International Shipmentsy, ❑Import to U.S. ❑Export from U.S. Port of entry/exit Z Transporter si nature for exports only): Date leaving U.S.: IX w 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day yew zTransporter 2 Printed/Typed Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J � LL FacilitYs Phone: �A�� 5 2018 p LU 18c.Signature of Alternate Facility(or Generator) Month Day Year At Mr 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) fir. 1. 2. 3. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year EPA Form 6700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY