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Please print or type.(Form designed foruse on elite(12-pi, tch)typewnter.) Form 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 C A D 9 ,R 2 5 4J tr �} � � � �f�.��t� 000250478 JJ K 5.Generator's Name and Mailing Address GeneralDr's Site Address('d dd_ferent than mailing address) Urvtm4l Westwn Grocers Ath,Pat GUI* r*ty, 5.204 Shelia Street .1 €-16oildcR CIA. Generator's Phone: ' A 4 - 6.Transporter 1 Company Name. U.S.EPAlD Number Haz Mat;brant, Inc., C A T O 8 0 0 1 2 f_t 0 0 7.Transporter 2 Company Name U,S.EPA ID Number- r 8.Designated Facility Name and Site Address U.S.EPA ID Number Crosby&t"4wftk"01 1 11V30 ir"1d, 17th SV t - Long Such ;iC, 9,Wi Focality s Phone: ri�i Fi C A Q 0 3 4 U 9 V _t 4 I ga Rb.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(ti any)) No. Type Quantity Wt.Nol: 1' 'UN 19YSAS E AOrOSOIS€=#r�Mmt� 1 3 31 i 2. 2 LU r 0M ;f P 3 i 14.Special Handling Instructions and Additional Information . .1 r�« (� _ {�C:., :t 1..• j'�e t_5.411'. ! ; `? j G).,r've's C'i 15. GENERATOR'SfOFFEROR'S CER71FICATION: 1 hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, i marked and labeiedlplacarded,and are in all respects in proper condition for transport according to applicable International and natfona#governmental regulations.If export shipment and I am the Primary I Exporter,I certify that the contents of this consignment conform 10 the teras of the attached EPAAcknoMedgment of Consent I certify that the waste minimization statement identified in 40 CFR 262.27(a)(H 1 am a large quantity generator)or(b)(dI am a small quantity generator)is true. Generators/offeror's Printed/Typed Name Signature Month - Day Year 16,International Shipments � ��'❑Import to U.S. 77 F-1 Export from U.S.: Pori otentrylexit:' Transporter signature(for exports only): °" Date leaving U.S.: i I 17.Transporter of Receipt of Materials t Transporter 1 Pdntedlryped Name Signature. Month Day Year r Month Day Ye r Z Q ransporter2 Printedfrypad Name Signaturb 16.Discrepancy 1 18a.Discrepancy Indication Space ❑ �an6ty, ❑Type" ❑Residue ❑Partial Rejection 0 Full Rejection Manifest Reference Numbar.. 18b.Alternate facility(or Generator) U.S.EPA ID Number LL. Facility's Phone: Month Day Year t LU 18c.Signature of Alternate Facility(or Generator} Z N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) G 1. 2. 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item i Be - Printed ryped Name Signature Month Day Year II� EPA Farm 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY f1