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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 1 of 3.Emergency;Response Phone 4.Manifest Tracking Number e e WASTE MANIFEST LG ,.. "' r 5.Generator's Name and Mailing Adress' Generator'se' fres? ihf rf tlfan mailing address) We rR t oklt Stamm std W GSI ' J 6.Transporter 1 om U.S.EPA ID Number AdAW4d Okr . �,R: two�nw, .. X 11 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number t�+ Fac iitysf'Kone: 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 WtNol. CF V a PGG � , £ 141 tW2 h.x OV 4` ✓ '. � WAS*c' 4"m .�' s Y {y 1 ywg 14.Special Handling Instructions and Additional Information 3 4=kss� Baba ° +�» 13 T x "`v � If M 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 labelediplacarded,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/ s rintedfFyped Name Signature Month DayYes! _j 16.International Shipments ,:.�•... i- ❑Import to U.S. ❑Export from U.S. P6wdintryexit: Z Transporter si nature(for exports only): Date leaving U.S-: W 17.TransporterAcknowledgment of Receipt of Materials 6 Transporter 1 PrintediTyped Name. igna ure Month ay ear zrnsporteir2 PrintiedfTyped Name . Signature 1ATth Day ear., 18.Discrepzncy,_, 18a.Discrepancy Indication Space ❑ QuantityT e ❑ yp Residue❑ ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year Q z 55 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) UJ C3 1. 2. 3. - 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY