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_ori elite(12-pitch)typewriter.) 'i Farm Approved.OMB No.2050-0039 �� t.Generator ID Number 2.Page 1 of 3.Emergency Response Phone a.Manliest Tracking Number MANIFEST ' r P 'l•,' ' ry,w J J K m.us.i.2 1.r 5 G=_nerator's Name and Mailing Address Generators Site Address(if different than mailing address) Geneators Phone. - 6.Transporter 1 Company Name U.S.EPA ID Number 10 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number Facill Phone: - ga, 9b.LLS.DOT Description(Including Proper Shipping Name,Haxand Clan,ID Number, 10.Containers 11.Total 12 Ung HM and Packing Gmup(if any); No. Type Quantity 'Al13.Waste Codes 7: O w w 2. 0 3. a, 14.Special Handling Instructions and Additional Information 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and aauratety described shove by the proper shipping name,Ord are classified.packaged, marked and IabeleNplacarded,and are in OR respects in proper condition for transport according to applicable interrationaland 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 attached EPA Acknowledgment of Consent. I certify that the waste minimization statement Identified in 40 CFR 262.27(a)('d I am a large quandty,generator)or(b)INN am a small quantity generator)is true. GenryatorslO6eroes PdnteMyped Name - Signature,' - Month Day Year � 16.International 5hipmertts � i Z ❑Import to U.S. � ❑Expos from U.S. Pon of entryledt: Transporter signature(for exports only): Date leaving U.S.: w 17.TransporterMhnomedgmeat ofReceiplof Materials C Transporter 1 Prirnedrryped Name Signature MaM Da Year O y Is. l . .... Z Transporter 2 � Printedrrped NameQ Si wWre - Mprdh Day Year F— 18.Discrepancy a 18a.Discrepancy indication Space ❑ Quantity ❑TYPe ❑Residue ❑Partial Rejection ❑FWI Rejection J 18b.Alternate Facility(or Generator) Manifest Reference Number. U.S.EPA ID Number V u Facilitys Phone W 180.Signature of Alternate Fadlity lar Genemtcr) Month Day Year Q 2 H19,Hazardous Waste Report Management Method Codes(Le.,codes for hazardous waste treatment,disposal,and recycling systems) O 1, 2. 3. 4. 1 20.Designated FadiiN Owner or Operator Codification of receipt of hazardous materials covered by the manifest except as nleed in item 1be PnntedRyped Name Signature Month Day Year EPA Forts 8700-22(Rev.3-05) Previous editions are obsolete.