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Please print or type. Form Approved.OMB No.265 ' UNIFORM HAZARDOUS 1.Generator i0 Number 2.Page of 3.Erne gency Response Phone 4.#7anirest Tracking Number W0TeMANIFEST �� - i ,� - spy 022831136 JJ4� 5,Generator's Name and Mailing Address i..,/d 2L 0 �L.!�rl7f` Sz'��'/LI Generators 'ote Address(if different than mailing address) zl-,�a s' 5 r3 s� I�i ,•�au G g5'Is� Generafoes Phone: 6.Transporter 1 Company Name U.S.EPA l t Number r2u5 /, A-i-11 2G u w i*/e M L Ug) 7.Transporter 2 Company Name U.S.EPA 10 Number 8.Designated Facility Name and Site Address / ! f, //� ��Cy 1-4 5K,�7 ftfG U.S.EPA 1D Number 3a✓ D /� /�llo �c� G9L17 'll Facility's Phone: 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM end Packing Group(if any)} No. Type Quantity wt.Nol. o ' Lill"LU �, 2.l�.vl � �� S/`l Pmt-L-, 3.�vRl�Z�f /�i(��ri/3G/C1�1✓)�'eV6 �r�7A C-f X 51 4-1111 4- 14.Special Handling Instructions and Additional Informaty'on pie- G2� `l z fS `3 `�� 0?sf G1 ' G/2c `!Z�r *13- A0-' -y" l4�7�r 1 L 98 x5s" 9A - -/xs-5-i 963--lk-5- " I -11;>-u12 Len -e to A,- LAV,me2 A ijfe A ,Lj1PA 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 labeledlplacarded,and are in all respects in proper condifion for transport according to applicable international and national governmental regulations.If export shlpment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste min€mization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b ifl am a small Pity g erator)is true. Generatadsl0fferoris Printed ped Name //? Signature r Month Day y,�r�iv C�U►iv�9 Z 2 16.International ShipmenTs h— ❑Import to U.S. ❑Export fro U.S. P of entry ? Transporter signature(for exports only): Dale leaving U.S.: w 17.TransponerAdmowiedgmentofReceipt of aerials Transporter 1 !Typed Name Signature Month pay Z z Transporter 2 Printeal 1 ype ame Signature Month Day F 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue Partial Rejection ❑Full Rejectic 186.Alternate Facility[or GeManifest Reference Number:nerator} U.S.EPA ID Number j LRLL Facility's Phone: w10c Signature of Altemata Facility(or Generator) a Month Day Z N19.Hazardous Waste Report Management Method Codes(i e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 1 2. 3. 14. 20.Designated Facility Owner or Operator:Certitiration of receipt of hazardous materials covered by the manifest except as noted in Item 183 PrinledlTyped Name Signature Month Day EPA Form 87po 22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's PMANIFEST SY