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Please print or type.(Farm designed for use on elite(12-pitch)typewriter.) Farm Approved.OMB No.2050-0039 * UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3 Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST Wi, f 4 Y.l ] . r LE 5.Generator's Name and Marling Addressu et d. bdd r 11515 01 �I�rl�' this manifest,that NSSI has the appropriate permits for, and willaccept the waste the generator is shippi 110` Generators Phone: Ir„2P) , _ 6.Transporter 1 Company Name - U.S.EPA ID Number r( ) / 7.Transporter 2 Company Name U.S.EPA ID Number B.Designated Facility Name and Site Address U.S.EPA ID Number ;96L STiYri-'T.. Faciff 's Phone: ' ;13)— 6tv , d a 1 i ✓ '.. ';7, 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit e 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 1 I w �.r 3. p--�} �1t14 I 4. � EN IRO T 14.Special Handling Instructions and Additional Information rtC'�r !i;'in r V1!(1.� 4 r r. !i.+'” "4... 1�f`�.. S f a ( t. , F'6'i,l` ' � 4 rr 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classifed,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 EPAAcknawledgment 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)Iff I am a small quantity generator)is true. Genera[[pbrs/Offerofs Pnyynted/Typ vame igna ure f/iR T r on ay Year 15.Intemational'Shipments " Lr ' i— ❑Import to U.S. ❑Export from U.S. PAf entry/exit: _ Transporter signature for exports only): Date leaving U.S.: ,a 17.TmnspoderAcknowledgment of Receipt of Materials Transporter 1 PPnntedrryped Name Signature', Month Day Year .._._....._._..._ .. I ( ..,. 4 Transporter 2 Printed/Typed Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue 1:1 Partial Rejection El Full Rejection Manifest Reference Number: 18b.PRemate Facility(or Generator) U.S.EPA ID Number J U LL Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year a z N19.Hazardous Waste Report Management Method Codes(ieu,codes for hazardous waste treatment,disposal,and recycling systems)' 3. - 4. 14 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest ex4t asgoled in Item 18a Pdtr yped Na r / {` SignaN ` MoRtb DpY Year EPA Form 8700-22(Rev.3-05) Previous ediGonsamobsolete. DESIGNATED FACILITY TO GENERATOR