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Please print or type.(Farm designed for use on elite(12 pits writer.) Farm Approved.OMB NO.2054 0639 UNIFORM HAZARDOUS1'Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number �+ p WASTEMANiFEST >` 4te^ '. ,� YaY000059489U D F 5.Generator's Name and Mailing Address Generator's Site•AddremTO different than mailing address) un ��...;:..� € )X,�'.- '' k'c '"� / � l,.o+�.,c�'. 4� '"j�' �`��tri �' t.•C' !`: .� .E_..ir,;;i::7if. ��'.� Generators Phone: c. + °e T,; + ', !• 's • ". : r"" tt :1i::. - 6.Transporter 1 Company NameU.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number .Designated Facilii•"q and 5iteaFRd4",, U.S.EPA ID Number ut,J'',+i Facility's Phone: ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,;ID Number, 10.Containers 11.Total 12.Unit 131,Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.NoI- O a3'i?�T�.,��•�T �, c .r p �f 1�i"� i�` � �r .. . `/• 'r^� _ r,, {{[LLL S - Z 2. LU - - 3. 4. 1' .Special Handling Instructions and Additional Information, „ . :�• �.r' at W f •'0-+;t a io °� v,�,.f��Y.,tY R ee - °•4 k- F•1 � r'y,. 5 - ..t 6 � t.-t�TQC �� - • 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 labeledlplacarded,and are in all tespects in proper condition for transport according to applicable international and n6onal 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 EPAAcknowtedgment of Consent: I certify that the waste minimization statement identified in 40 CFR 262.27(aj('d I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generalor'slOfferoes PrintedlTyped Name Signature ' Month Day Year, ti 16.Intemational Shipments ❑Import to U.S. ❑Export from U.S. Port of eritrylexit: Transporter signature(for exports only): Date leaving U.S.: f 'JJJransporter Acknowledgment of Receipt of Materials ''° `' ' uj Transporter 1 Printed/Typed Name Signature c > Month Day Year f `� ..^y t t Y i✓ f +r..N. ..+ Z Transporter 2 PrintedrTyped Name.. Signature" Month ' Day Year 18.Discrepancy . ;. . 18a.Discrepancy Indication Space ::. ❑ Q ;' uantity ❑Type ❑Residue Partial RejectionFull Rejection. 4 _ Manifest Reference Number: - 18b.Alternate Facility(or Generator) . ,. ;,: yU.S.EPA ID Number, ._ r0- Facdityrs Phone: W 18c.Signature ofAltemateFacility(or Generator) _ Month Day .-rYear. N19,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and'recycling systems) O 1. 12, 3 4 _ 20-Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PnntedfrypedName Sjgnature Month "'Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY.r,