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Please print or type.(Forrn designed for use on elite(12-pitch)typewriter.) Forni Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1 Generator ID Number 2.Page T77cy,Response Phone 4.Manifest Tracking Number p WASTE MIANIFEST .) 1 7 G B F 5.Generators Name and MailingAddress k'lenerators Site Address fir different than mailing address] J Generators Phone: 6.Transporter t Company Name U.S.EPA ID Number 7 Transporter 2 Company Name U.S.EPA ID Number B.Designated Facility Name and Site Address U.S.EPA ID Number Facility's Phone: ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,10 Number, 10.Containers 11.Total Q.Unit HM and Packing Group(if any)) No Type Quantity Wt.Nol. 13.Waste Codes w 3. 4. 14-Special Handling Instructions and Additional Informaton t 5. GENERATOR'SIOPFEROR'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 labelediplacarded,and are 0 all respects in proper condition for transport according to applicable intemational and national governmental regulations.If export shipment and I am the Primary Exporter,I certify Ihal the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identfied in 40 CFR 262.27(a)(if I am a large quantity generalor)or(b)(ifI am a small quantity generator)is true. Gener3lorsf0iferor"s PriniedfTyped Name Signature Month Day Year r ' ..� 16.1IntemationalShipments F ❑Import to U.S. ❑Export from U.S Port of entrylexit z Transporter signature(tor exports only): Date leaving U.S.: LLA 11.TransporterAcknowledgmenl of Receipt of Materials � Trarspoder 1 Printed/Typed Name S*y Iure Monde Day Year C) - 0- Q Transporter 2 Pdntedrryped Name Signature Month Day 'fW w t6.Discrepancy 18a.Discrepancy indication Space Quantity ❑Type ❑ ej Residue i�J Partial R r><uon El Full Rejection Manifest Reference Number 18b.Alternate Facility(or Generator) U.S EPA tD Number J - V LL Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year a Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 26 Designated Faolity Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as rioted in Item 1 Be Prfntedffyped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INMAL COPY