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Please print ur type.(Form designed for use on elite(12-pitch)typewriter) Farm Approved,OMB No.2050-0039 [IT-51. NIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number �] p WASTE MANIFEST "fM+.I a ;;,u: t; if'F+$r., 0 0•� j.C7 V r�2 J G D Generator's Name and Mailing Address Generator's Site Address(it different than mailing address) Generator's Phone: 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name US EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number �,I•;;JJ 1'.41.I;.r1lr,tgctliNltatn+W_cnras9l Facility's Phone. ga. 9b.U.S.DOT Description(inducting Proper Shipping Name,Hazard Class.ID Number, 10,Containers 11.Total 12.Unit HM and Paddrig Group(if any)) r 3.Waste Codes No. Type Ouanbty NLNd. w w z 3. 4 14.Special Handling Instructions and Additional Information r 3,., l 15 GENER476R'S10FFEROR'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 Iabeledfplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental fggui tf export shipment and;am the Primary Exporter,I certify that the contents of the consignment conform to the teras of the attached EPAAcknowlerfgment of Consent. I certify that the waste minimization statement identfied in 40 CFR 262.27(a)(91 am a large quantity genoraloE)or(b)(if I am a smal quantity generpiar)is true. Ge tor's/Oleror's Printedfryped Name Signature Month Day Year f � 16.international Shipments ❑Import to U S. ❑Export from U.S. Port of entrylexit Transporter signature{far exports only): Date leaving U 5.: w 17.Transporter Acknowledgment of Receipt of Materials sportelt PrntedlTypedN O 41--n *nature r Month Day Year Tran a. r 1 1 i a Z Transppter 2 P61utyped Name Signature Month Day Year F 18.Discrepancy 16a Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Relectk Manifest Reference Number: F 18b.Alternate Facility(or Generator) U.S-EPA ID Number U LL Facility's Phone: W 1 Be.Signature olAtlemate Facility(or Generator) Month Day Year d Z 19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems) 4. 20 Designated Facility Owner or operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 16a PrintedfTyped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. °— GENERATOR'S INMAL COPY