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' 11 Please print ortype.(Formdesigrsedfor'use onelite(12-pitcfij• iter.) " Form Approved.OMB No.2050-0039 1."t3enerafor ID Numhe r",; 2.Page 1 of; 3.Emergency Response Phone.. 4.Mani{est Tracking Number UNIFORM HAZARDOUS ;Ij.. . '%"� .,, `,'i '.�'p" G B F WASTE MANIFEST µ S.Generator's Name and Mailing Address. Generator's Site Address(if different than mailing address) '.s•?'i -.' a' c ^' - F." 4�,S t� ,:{'TY:. i�^}�.,• v ,i" _s 1,` s'�f..."k-f:L'. - - •Y:'�4�-..?j.`.'.-.1' ., ,YyL�t:1:JG I� '�,Li. if...}�.fl.:.�t - Generator's Phone " 6.Transporter 1 Company Name U.S.EPA ID Number -,. ,J>-vti�f: �•- . . �•P 't; it?.5 '' '4 j}$;{n: 7.Transporter 2 Company Name U.S.EPA iD Number 8.Designated Facility Name and Site Address U.S.EPA ID Number - ':;y_ Facility's Phone: 9a• 9b.U.S.AOT Dascriplion(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.UnR 13.Waste Codes HM and Packing Group(if any)) No. Type" Quantity WI-Not. Q' 1 ..r r�•ri fi.tr �.. .r'Fp S';'.'t"r'Ff'r i`�`". .fig:. _ .... 51 ." �-.P�a'"dl's= -. -, :i. ✓�,:a ,":7.�rw;? EYP�y , � `{,,! „w .-. t�.- Z 2. - - - 3. t 4. 14.Special Han)ling Instructions and Additional Information i - 'f.�i�-�,.�- �:.}� � �€� •f5"#'2„�r?S . -;� �. ?� ':9i;, ,x°. ,''''tl,t:'. .� F `�� :�e5 .;7f��ti`•u,f 3:�. "�. •ckgsx�:ti� 'r_�va'i:`_"'.Y''3'`�.�_," - �-. i 15. GgNERATOR'SfOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately desadbed above by the proper shipping name,and are classified,packaged, marked and Iabeledlplacarded,and are in all respects in proper condition for transport according to-applicable international and national governmental regulations.If exportshipment and I am the Primary " F:r 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)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. < - Generators/Offerors PrintedlTyped Name Signature- •...,_t, .-. Month Day Year J 16.International Shipments F •. ..' ❑Import to U.S. ❑Export from U.S- Porto on ext: z Transporter signature(for exports only): Date leaving U.S.: w 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 PdntedfTyped Name Sgdt re 5, Month Day Year QTransporter 2PrintedlTyped Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ,, ❑Type ❑Residue ❑Partial Rejection ❑full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA[D Number tai Facility's Phone: Lu 18c.Signature of Alternate Facility(or Generator) Month Day Year" N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and.facytling systems) Lul 1. 20.Designated Facility Owner or Operator.Certificaton of receipt of hazardous materials covered by the manifest except as noted in Item 18a " PrintedlTyped Name &gnature Month Day :Year. EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INMAL COPY