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j ♦.• � �l klease print or type.(Form designed for use on elite(12-pitch)typewriter.) FA94&UOi UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST 'CA CC)O a�W LL 3 1 000-Y,93 -311A 009562730 FLE 5.Generator's Name and Mailing dress w�,T ` 1 Generators Site Address(if different than mailing address) Generators Phone: ransporter pony ame 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 �1 ba,� �� GSt�,a.c�-s-c• (._a^nr` ��V�erS��k�- �� 3�3 �"l �, �L (3� D�. 3 5"�i Facility's Phone: �o�— ga 9b.U.S.DDT Description(including Proper Shipping Name,Hazard Gass,ID Number, 10.Containers it.Total 12.Unit 13.Waste Codes HM and Packing Group(deny)) No. Type Quantity WtNd. 1 N o0 -,e t9-i4- - 1-X C)0� 3 Z 2. W 3. 4. 14.Special Handling InsUuctiom and Adddtlonal Information 15. GEN ERATOR'S1OFFEROR'S CERTIFICATION: I hereby declare that the conten of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, masked and labeledlplacarded,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 cons gnment conform to the terms of the attached EPAAcknowledgment of Consent. I certify that the waste minimtration statement identified in 40 CFR 262.27(a)(d 1 am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generatoee Pdnte&Typed Name ,sign a re • on y Yee 16.International Shipments Z ❑Import to U.S. ❑Export from Urt of entry/exit Transporter nature for ex only): Date laving U.S.: 17.Transporter Admowledgmenl of Receipt of Materials ITra r 1 Prin yped i re ay Year a ��`C1� L �o � Q Transporter 2 Printad/Typed Name Signature Month Day ear i 18.Discreparuy 18a.Discrepancy Indication Space 5r�uan6ty ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection 5 Manifest Reference Number: 18b.Alternate Facility( nemtor) U.S.EPA ID Number U Q LL Fadli s Ph 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z ti19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) G 1. 2. T 4. 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Prin yped Name Signatu Month Day Year O 1 EPA Form 8700-22(Rev. 5) Previous editions are obso ete. �ffll§NATED FACILITY TO DESTINATION STATE(IF REQUIRED)