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Please print or type;(.orrh designed for use db elite(12-pitch)typewri(or.) , Form Approvedi OMB No.2050-0039 UNIFORM HA2L1Rp0U5 1:Gene gator)D Number _ 2 Page.:1 of: 3.Emergency Response Phone 4.Manifest Tracking NuYnber WASTE MANIFESTGB F 5 Generator's Name and Malling Address ", tp Generator's Slle Address(If different than mailing address), , Generator's Phone: 6,Transporter 1 Company Name' U.S.EPA ID Number 5 ..5,➢ }.a i� yt.-. '.-,.,e ��:,f'.,,�.:.tti-:4 �,a+�... .•� ,1}.. _' --'.L, 7.Transporter 2 Company Name U.S.EPA ID Numberi; B:Designated Facility Namd qhd Slte Address "„ " :U'0S 117AT Numbe' Facility's Phone: 9a, 9b:U.S.DOT Desc6ptlon,(iricluding Proper Shipping Name,Hazard Class,b Number, " 10:Containers, 11.Total 12,Unit HM . and Packirig Group(if any)) No. Type Quantity wt,Nol, 13.Waste Codes. I 400 i.. - t.Special Handling Instructions and Additional Informationtr t' � t- a1r' r f - ! =b 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 cNsslfietl,packaq>d, Marked and laboledlplacardod,and aro in ail respects in proper condition for Iransportaccording to applicable Inlemallonal and national governmental regulations:If export shipmentand I am the Prlmaiy Exporter;l.certify that)he contents of tills conslgnment conform to the terms of the attached EPA Acknowledgment of Consent.. I cei8ly that the waste minlrnlzalion 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'slGlferor's PnnrrtedfTyped Name } Signature j Month Day Year jrt/l kl r C, fJ�. = 5I" 1r i {:/f t( rl' + :-,'4 16,6temallonalShipmentss+ L i— ❑import to U.S. Export from U.S. Port of entrylexit• Transporter slgnaiure(for exports oniy), ;'-' Date teavin U.S.: 17.TranspofterAcknowiedgmentofReceiptofgate Tials tE Transporter I PnntedJTyped Name. Slgnatu 7{' Month Day Year i€,�,i.;r i?� 9t. Ff'r t 7 •-, I'! �+ -:,� V• , ,:�t �la �! 31 A. .�'f .L'i _ +� Transpbier2PrinterypedName Slgna(ur@r 4 Month" " Day., Year 18.D€screpancy y' '18a•Discrepancy Indicatfon Space; ❑ Quantity ❑Type ❑Residue ❑Partial Rejeallon ❑Full Rejectlon Manifest Reference Number: 18b Alternate Facilrly,(or Generator ! U.5 FPAt�.(Jtimber Q Facility's Phone. 18c.Signature of Allefnate facility(or Generator) Month Day . Year G z 10.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous wastelreaiment,disposal,and recycling systems) 3: 4. 20 Desi"gnaled Facility Owher or Operator:CeriifcatlQn of recefpl of hazardous materials coverod by i'e manifest except as noted In Item 18a Printed/Typed Name6'" Signature — J Month Day Year Ot�EPA Form 8700-22(Rev:3-05) Previous editions areobsolete: i _