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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approv 0(1 � UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone .Manifest Tracking NLKnber �a WASTE MANIFEST 60��`L-13 �v-Y —3�)81" 009562730 FLE 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) 75.31.0 �v- t e -Generator's Phone: � ransporter Y erne U.S.EPA ID Number Uv►N�,�,� �u� �✓ M- A 0 0-3 13 as.1 S- 7.Transporter 2 Company Name U.S.EPA ID Number a.Designated Facility Name and Site Address U.S.EPA ID Number 0-q►cam�,�,—c ��r ba,p �' (��w.cyc c_.b,n� ��►V�rs .�►c+ �A X3,33 0-'l C At' On 5-'j Facfli s Phone: to 61— —S' ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Gass,ID Number, 10.Containers 11.Total 1 12.Unit HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes 0 1 N o� 2 IC-IL Ar- -�l WL A,4k-1D WAS I-,J"It, 00l C 3 It ) C 8% a�) t V 00 Z 2. W t9 3. 4. 14.Special Handling Instructions and Addtional Information 'r, wrx 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the conten of this consignment are fully and accurately described above by the proper sNppN name,and are classified,packaged, marked 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 F)porter,I certify that the contents of this axrsownent 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 1 am a small quantity generator)is true. s! Name Signature • Month Day Year A ��iv�� Ito 5 11 16.International Shipments f ❑Import to U.S. ❑Export from U rt of entryleA Transporter signature for exports on : Data leawng U.S.: 17.Transporter AcioucMAedgment of Receipt of Materials Tra 1 PriSi: re on ay ear 0 t o e Q Transporter 2 PrintedRyped Name Signature Month ay Year t 05 18.Discrepancy 18a.Discrepancy Indication Space Quantity ❑Type ❑Residueej ❑ election ❑Partial R action Full R A(YVAI Q4 t 5 Manifest Reference Number. —Alternate Facility( nerator) U.S.EPA ID Number U Q LL Facility's Ph ne: W 18c.SignaWre of Allemate Facility(or Generator) Month Day Year Q Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) UJ G 1. 2. 3. 4. 20.Designated Fadlity Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signatu Month Day Year Ito 1011 I) EPA Fam 8700-22(Rev. 5) Previous editions are obsolete. I NATED FACILITY TO DESTINATION STATE(IF REQUIRED)