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Please print or type.(Form designed for use on elite(12-01 ,typewriter.) to Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3 Emergency Response Phone 4.M((a'��nl/e�at Tracking Number WASTE MANIFEST U V 7 cl n JJ K 5.Generator's Name and Mailing Address Genmati Site Address(if different than mailing address) 1 t?;7d1 w Elx3d'IT IA'it P'41 Generator's Phons: 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address Cf1EP.1.. - U.S.EPA ID Number 35I LAW yH: iJf•If_f';l^'!} .. utFTTl.E1d.fd G11 F C..= ;e';:=.'33 Facility's Phone: ga,_,„91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total-— -12.Unit -- HM and Packing Group(ff any)) No. Type Cuantify WWoI. t3.Waste Codes I. h ) a O y) z w z 2 w U 3. I 4. 14.Special Handling lnstnhcticns and Additional Information J�, r��n ilN 1,1'a r:¢II_P:E' F!p(,yii;'1 W L Hal'ft)t_t�i�:5 �itrt_IfA HF 'pFFARN'D as,� l.)"_aP. Ott.i'Q ti'l't° 15. GENERATOR'SIOFFEROR'S CERTIFICATON: 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 governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment cordorrn to the terms of the attached EPAAcknowedgment of Consent. I Panay that the waste minimisation statement identified In 40 CFR 26227(x)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. GeneratofstlJterols Printedfryped Name Signature Month Day Year J 16.International Shipments 'r ❑Import to U.S. ❑Export from U.S. Pod of entry/exit: Transporter signature(for exports only): Data leaving U.S.: w 17.TransporterAdmorNedgment of Receipt of Materials Transporter 1 Printedrfyped Name Signature Month Day Year a Transporter 2 Printedrryped Name Signature Month Day Year K r 18.Discrepancy 18a.Discrepancy Indication Space ❑ Cuantity ❑Type ❑ResidueEl Partial Rejection ❑Full Rejection Manifest Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U Facilityrs Phone: 18c.Signature of Alternate Facility(or Generator) Month Day Year zZ y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) G 1. 2. 3. 4. 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Rem Ise PdntedrRyped Name Signature Month Day Year EPA Fom18700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITfAL COPY