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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No:205.0-0039 1.Generator ID Number 2.Pae 1 of 3.Emergency Response Phone 4.Manifest Tracking Number UNIFORM HAZARDOUS 9 enc Res 9 y p --:,; WASTE MANIFEST :r, ' JJ K 5.Generator's Name and Mailing Address Generator's Site Address(f different than mailing address) w., ., TI , Generator's Phonetr'r4-y-,' ; i 6.Transporter 1 Company Name U.S.EPA ID Number i'.;;:4- a`;Zk. 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address. !_;c• c iv' ;"`:3i'ft?C i3 , =:"' >•t s fr'ttt U.S.EPA ID Number• ,f n,;,-„g�. •« Facility's Phone. ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Wasle Codes HM and Packing Group(if any)) No. Type Quantity W1Nol. 1. ;'t(:,f; r:r:. Fi,V;4h'f511E.i3 F. ._i(`i �rc:i. ,ti F..r;1 ,�-`s�• z 2. LL) --I �- 1 I _ 1 3. j r r 4. ( ! 14.Special Handling Instructions and Additional Information " fTr`E. .. fitC1'."i I'S lir F"PE 15. GENERATOR'S FFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and,accurately described above by the proper shipping name,and are classified,packaged, marked and labeled/placarded,and are in all respects in proper condition for transpoil according to applicable international and national governmental 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 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 srllall quantity yeorator)'ys We. Generatorsl0lferor's Pdntedrryped Name Signature ;;' -"" •% ! Month Day Yeas J 16.Intemetionef Shipments F-- ❑Import to U.S.u ❑Export from U.S. Port of entry/ext., z Transporter signature(for exports only): Date leaving U.S.: w 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printedfrxped Name Signature Month Day . Year Q t ( �' r a ,�'--•�. r'..4.-I 'y�i`.;'--�'^t 13 t,. -I !::<: • .... L�! ti': .ri l_..Et°�.� !`.`-- <�` Flu � .r M Transporter 2 PrinllddRyped Name Signature Month Day Year, a F- 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity QuanG El Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: Fy j 18b.Alternate Facility(or Generator) U.S.EPA ID Number U Facility's,Phone: w 18c.Signature of Allemate Facility(or Generator) Month Day Year 1 y 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) O 1. 2.. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 182 Printed/ryped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY'S COPY