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Please print or type.(Form desi ned 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,Manifest Tracking Number WASTE MANIFEST A 1, ff I) +' I Fifi%;1 It'.4 i1w JJK 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) E. KE HUM RU GlXlI r.:A y"..'?*) Generator's Phone: KPS - 1 fy lify I 6.Transporter 1 Company Name U.S.EPA ID Number A13RORY E RONWN TAL SERVICE:,, ' y ` 7 7 0 3 A 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number RfEhC-Mi I1+IIX$URY IN- 3175 S,OU1f14130YLE AVE"JE A 1KA A Cr 0 Facility's Phone: W3177e IN-10- go, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 0.Cama Hers 11.Total 12.Unit HM and Packing Group(if any)) No. Type Quantity WtNol. 13.Waste Codes 1. � t p i+fC.X4•RCE2AHAZA~'ClC►l.S WASTE,S-.#.ID(011,Y SUIDS) UJ 2. LU Sr f 3 r 14.Special Handling Instructions and Additional Information €»IVa RGENC Y#iON AQ J . C*11EM E-C 1-0W-4Q4-1 XX)NAER(3# 8I V t t!$t-J4}1tC":#9191 AN t+'.F A0+.At.Y '-tULICJS K4 Al 1016 4021 "APPIRC If"RIAIE.PERSORAL RROI"C c RVE E:(X#F*fNT 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 labelediplacarded,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(x)(if I am a large quantity generator)or(b)(if I am a small quantity generator)Is true. GeneratoeslOfferofs PrinteCyped Name Signature Month, Day Year —J 16.International Shipments ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Transporter signature(for exports only): Date leaving U.S.: 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 PrintedfTyped Name Signature Month. Day Ypear, d QTransporter 2 PrintecTryped Name Signature Month Day Year 18,Discrepancy 189.Discrepancy Indication Space ❑ Quantity ❑Type El Residue ❑Partial Rejection Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J V u- Facility's Phone: 18c.Signature of Alternate Facility(or Generator) t,',,wh Day Year H19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) Lull. 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 Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY