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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.-OMB No. UNIFORM HAZARDOUS 1.Generalor ID Number FPage of 3.Emergency Response Phone 4.Manifest Tracking Number 2050-0039 WASTE MANIFEST `- ;t �;•. J J K. r.: '�• 'S' d, 5.Generators Name and Mating Address Generator's Site Address(if different than mailing address) Generator's Phone:`'`' 6 Transporter i Company Name 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 Facility Phone: ga. 9b.U.S.DOT Description(Including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) t3.Waste Codes No. Type Quant ty WtNol. 0 3. --- -- 4 — - 14.Special Handling Instructions and Additional Information tt ..'r:'. ... .. 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classed,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 allached EPA Acknowledgment 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.trbe. Generators/Offeror's Prinledfryped Name Signature Month Day Year i F16.International Shipments z ❑Impart to U.S. ❑Export from U.S. Port of ontrylexit: Transporter signature(for exports only): Date leaving U.S.: Ce 17.Transporter Acknowledgment of Receipt of Materials oTransporter 1 Printed/Typetl Name' ; Signature Month Day Year CL ? a Transporter 2 Pdh!ddR0e8 Name` Signature Month ' Day Year f— I'- Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number. 18b.Mlemate Facility(or Generator) U.S.EPA ID Number J U ua.- Facility's Phone: w 18c.Signature of Allemate Facility(or Generator) Month Day Year a Z N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 1' 2• 3. 4. 20.Designated Facility Owner or Ope.ralor.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year _...__..,.__.-. ._..._ ._- ... y 1 .f I EPA Form 8700-22(Rev.3-b5) Previous editions are obsolete. nGclrnterr;n Gnrtr rTvrc rnov