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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1•Generator ID Number 2.Page i of I Emergency Response Phone - 14.Manifest Tracking Number c WASTE MANIFEST ' , . 010242939 L��G 5.Generator s Name and Mailing Address Generator's Site Address(if different than mailing address) C Skxltan Generator's Phone: "AWIM 6.Transporter 1 Company Name U.S.EPA ID Number Ado-W#�.AW TI&WA 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designate_.Facility Name and Site Address ## .... U.S.EPA ID Number cum , _Lr �M GA Facility's Phone: ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity .. Wt.Nol,. . ,,.:, tKtype�a. € o $ ..: owl Z 2. LU 3. 4. 14.Speciall Handling Instructions and Additional information 15. GENERATOR'SIOFFEROR'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 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 conform to the terms of the attached EPAAcknowledgment 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 small quantity generator)is true. Generator's/Of eror's Printed]ryped Name signature Month Day Year 73 -j 16.International Shipments F ❑Import to U.S. ❑apart from U.S. Port of entry/exit: Transporter signature(for exports only): Date leaving U.S.: 17.Transporter Acknowledgrrent of Receipt of Materials LU Transporter 1 Printed/Typed Name Signature Month Day Year ct Q Transporter 2 Pdnted/fyped Name~ ignature H 18.Discrepancy IBe.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑FuN R. Manifest Reference Number: I 8b.Alternate Facility(or Generator) U.S.EPA ID Number J V LL Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year 4 z 05 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) p 1 2. 3. 4. �jlity Owneror Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INMAL COPY