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Please print or type.(Form designed for use on elite(12-pitch)tyy'ter.) • Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1 1.Generator ID Number 2.Page 1 of 3 Emergency Response Phone 4.M0153841K,1 aaynif+l TraCkkiinng Number �( WASTE MANIFEST \/ y l^'. /-._ •:r', Tl-](/ ( :[.i U-I 5 3 8 s'!1 K a JJ K 5.Ceneral Name and Mailing Address Generator's Site Address(d different than mailing address) � r Generatots Phone: I - 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Sde Address U.S.EPA ID Number Facility's Phone: / - - 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total Vi12.Unit HM and Packing Group('d any)) No, Type Quantity W 13.Waste Codes 1. C QO w w 2. c� 3. 4. _ 14.Special Handling Instructions and Additional Information - 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 Iabeledrplacarded,and are in all respects in proper condition for transport according to applicable intemational and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment canform to the tens of the attached EPAAcknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(g I am a large quantity generator)or(b),(if I am a.small quantity generator)is true. GeneratofslOfferaft PrinledRyped Name Signature _ .._. .. - -- Month Day Year -z16.International Shipments Z ❑Import to U.S. ❑Export from U.S. Pon of entrylexk: Transporter signature(for exports only): Date leaving U.S.: w 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed(Typed Name Signature Month Day Year O a y 4 Transposer 2 Prtntedlfyped Name Signature Month Day Year K .k 18.Discrepancy 18a.Discrepancy Indication Space ❑ Otnml ❑Type �❑Residue ❑Partial Rejection ❑Full Rejection R MLS 18b.A1temate Facility(or Generator) U.S.EPA ID Number MAY 0 2 20,1 LL Facill Phone: w 18c.Signature ofAltemate Facility(or Generator) ENVIMNMENTAL fir I Tf) Month Day Year z - KIMIT/SER'PCE� 55 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) U 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 PdMedlTyped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY