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�&o ll,� �,*A/ � Please tint or type, orm designed for use on elite (12• itch) typewriter,) � 6 Form Approved. OMB No. 2050.0039 UNIFORM HAZARDOUS 1. Generator ID Number 2, Page 1 of 3. Emeency Response Phone 4, Manifest Tracking Number WASTE MANIFEST (/)( / 015384426 JJ K 5. Generato rs and � I�g dress �SS ,� � enerators Site Address (if ditieren than mailing address) ;1� 2 2 S. s�Nc,LAirt �_ �Tb1� Generator's Phone: 12U, fbW 6. Transporter 1 Company Name U.S. EPA ID Number T S 0414 M0 L 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address ,Q�^L,_� U.S. EPA ID Number Facility's Phone: �� 98, 9b. 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 (if any)) No. Type Quantity Wt.Nol. e 1 30 7 MIr ff+20wI 904435 wroZC if 5ou9 1� poa�l Z 2, UJ 3. l 4. 14, Special Handling Instructions and Additional Information 0H1W9 CaUc ET 16. GENERATOR'S/OFFEROR'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 labeledlpiacarded, and are In all respects in proper condition for transport according to applicable International and national 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 EPAAcknowledgment of Consent. certify that the waste minimization statement identified in 40 CFR 262.27(x) (if I am a large quantitygenerator) or (b) if I an a small quantity generator) is true. Generator'si0fferor's PrintedlTyped Name Signal Month Day Year lG� CAJ Z OZ —r 16. International Shipments F ❑ Import to U.S. ❑ Export from U.S. Port of entrylexit, _ Z Transporter signature (for exports only): Date leaving U.S.: w V. Transporter Acknowledgment of Receipt of Materials 7ransporfo 1 Prin er_l/.Tylpa'd �mo CnZa Month Day Year f aLy ?J�kQ Tran porter 2 Printed/Typed Name Month Day Year a 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: 18brn . Alteate Facility (or Generator) U,S, EPA ID Number J U LL Facility's Phone: w 18c. Signature ofAllemate Facility (or Generator) Month Day Year z rn 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 3. 4. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest exc t as noted in Item 18a PrinledlTyped N Signature Mat lh Day Year T49 1.1EPA Form 8700.22 (Rev. 3.05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED)