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Form Approved. OMB No. 2050-0039 GENERATOR UNIFORM HAZARDOUS WASTE MANIFEST 1. Generator ID Number C 111_6005'C 5" /co. 2. Page 1 of i 3. Emergency Response Phone 8O0 -6- ?0?e, 4. Manifest Tracking Number 0 2 3 2 9 5 3 0 4 JJK Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) us- F ga_ clda Ltia_ 7 -V / C- ISoo Out-looK _sit. Soi't‹.. icie) IY95" b-- Pesradeed 4 v c_ 0 ve-v i.t t I ',eV' I(, i< 71" 66 '2 " Generators Phone: ( if row - Oa- X966 I Ta. c-i , G- 4- 9 ,.5-.2 o y Transporter 1 Company Name U.S. EPA ID Number A ille ilki /144..y,;</e__ I CAD'13 Tr porter 2 Company Name U.SAPA ID Number i I C IA)) c,1-__c LI te-Lo i q D C lik/ gi7 OV LrfOrl Lfr‘ C._ Designated Facility Na ind Site Address U.S. EPA ID Number C- V.05)1/ A el vev d-mi, 1630 GO r7f -4-t s r• L e xii g.. 6 ea4-k- , 6-- A eieft.-r Facility's Pie: yjg.._ 5 5, y_r IC 4 06 g 09 ye, 7,0/7 .5-4 el_ 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10, Containers 11. Total 12. Unit 13. Waste Codes 9a. mi and Packing Group (if any)) No. Type Quantity VVI.Nol. 1. t ) dji 12-C-R IfI-- /4 ‘ 1 c cle f cif (,ti a .s- f- e_ / h'el. C pie cie 4 p ,S" I OF 1.5-6 f 2. 3 4. 14, Special Handling Instructions and Additional Information FALI--q40'/.3 • 17'/3o/ La- 045:r 5Z • DA- 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, aid are classified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national govemmental 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. Generators/Offerors Printed/Typed Name , Signatu -- --..---- -------- - Month Day Year I I II I 9 I2Z L LI , Air? n CP t--c+011y I-- z 16. International Shipments Lii from U.S. Port of entrylexit Import to U.S. Export Transporter signature (for exports only) Date leaving U.S.: TRANSPORTER II 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day Year 'AL..-- Fr__,,_-___ I 11 I IP:5- O ste, (Go I Tran r 2 Printed/Typed Name Signature Month Day Year I H We I 2.2-- DESIGNATED FACILITY Ii 18. Discrepancy Discrepancy Indication Space Quantity Type LI Residue LI Partial Rejection LI Full Rejection Manifest Reference Number: Alternate Facility (or Generator) U.S. EPA ID Number Facility's Phone: I Signature of Alternate Facility (or Generator) Month Day Year I I 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 1. 1,..A \ ‘.4 \ 2. 3. 4. 20. Designated Facili y Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as cted in Item 18a Printed/Typed Name ch,c c 1 CA Lt)p-6- Signature 1 "Th Month Dbi lie,..a. ( 1 u 0--•ri __._..........................•.........,,•,___ w nin-tTr,r Ewe-rem EPA Form 8700-22 (Rev. 124.7) Previous editions are obsolete.