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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB Na.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of3.Emergency Response Plane 4.Nearest Tracking Number WASTE MANIFEST 0 5 2,o1--77q---)&q-!f 010 8 7 5 0 7 0 JJ K 5.Generators Name and Mailing Address Gen tors Site Address(it different than mailing address) 56S ►2T�(lij 106- ZZZz. 5. s I0C * N vE 07WUcTo,v Ci Genoatoes Phone: w ` 6.Transporter1 Company Name U.S.FPA ID Number N2 c5et Z 7.Tmnsporter2Canpany arra U.S.EPAI Number 00 f O 5E I ISD ZZZ5 0 a.Designated Facility Narneand neAddmss U.S.EPA ID Number Gt,�A+v �tk&Q-5 �E�rYcssr� " - �s733 Facirdy's Phon : $ —07 rO C— ge So U.1-06T Das dptlen(including Proper Shipping Name,Hazard Class,ID Number, 10,Containers 11.Total 1 12.Uri' HM and Panting Group(A any)) No. Type Quantity WINd. 13.Waste Codes o t A/A 30-7'7 M'012- "au5 k,t1q,5T15:, 2Np, 30771 07-44DOU5 GATE, of 0 0 5 G Q21 GF 312og i — IJl4Z7 RYi'LW a-oWj LAJATE , 02 4.A)oA)t _,zcza , owza12-1159I 02 M 14.Speaal Handling Instructsand Addti ( VL4-5T rk tint s N2�o ftul` G�+ �7 2-)1 (,qyt otz9 t EA I (CH 56-19 Erna V �s �� z e-nytq"s 2 ue u,V45 Z. 64�t 3;,51 R o GENERATOR'SIOFFERl7R'S TIHCA : I hereby ded the contents of ma consignAnt are Mly and aarimey describedabove by Ihz proper shipping name,and are classified,packaged, marked and labeled/pkanled,and are in all respects in proper condition for transport according to applicable international and national govemmental regulations_If export shipment and I am the Primary Exporter,I cerlAy that the contents of this consignment conform b the terns of the allachad EPAAcIma dedgment of Consent. I cenfy that the waste minlmuratbn staternent identified in 40 CFR 262.27(a)(d I am a Large quantity generator)or if I am a small quantity generator)is true. Geramdors101ferces Pnrded ped Na Signa Monro Day Year 2 tfb 65 16.Internmonal Ship Is i— ❑Impadto U.S. ❑Export from U.S. Port of entry/exR� = Transporter signature(for exports only): Date leavirg U.S.: w 17.TransporterAdanowtedgment of Receipt of Materials Transporter 1 Pdntedrryped Name Signature Month Day Year O y Q Trinspoder 2 PrintedRyped 8WZ-in lY 18.Discrepancy v 18a.Disaeparoy Indication Spm ❑ Quantity ❑Type �'x'x77�� p�p'LITCeslduk, ❑Partial Rejection ❑Fu11 Rejection Manifest Reference Number: 11th.Alternate Facility(crGeneato) pp gr{{ U.S.EPA ID Number WAW 2W/ LL Facilitys Phone: w roc.SignaNm of Alternate FacilRy(or Geneabr) ENVIRONVEN 1 Month Day Year a PE RM ITIS ES z N19,Hazardous Waste Report Management Method Codes(.e.,codes fa harardo is waste treamhent disposal,and recycling systems) 2. � 3. 4. t ISI 1 20.Designated Facility Owner or Operator Certification of receipt of hiscarclotts materials covered by Une manifest except as noted in Rem lot Printed/Typed Nyrra rt S MR / y year, Wp EPA Form 8700-22(Re v. -05) Previous editions are obsolete. DLS0flATED FACILITY TO DESTINATION STATE(IF REQUIRED)