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Please print or type.(Form designed for use on elite(12-pitch)typewriter) - • Form Approved.OMB No.2050-0039 } UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of merge cy RRstomme Phone 4.Manifest Tracking Number WASTE MANIFEST ' ,' ' I q- 015384304 J J K 5.Generelors Nama and Mailing Address `Generator ite Address(if different than mailing address) F,S t-� S C C_P5v PQ—CC—Q55 I YJ&— N IJ5, (�Gj( 1►2 LAVE • SToc'ilz�TnN Gene store Phone: 6.Tmnspoder.1 Company Name ' U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number US CCa -06 it MICCS 3. dF (z�� r�"t7y , �1 TTL NElJ14� � Uig : Facthy's Phone: ZnQ - — ?j ftj UT OocU ga 96.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers11.Total 12.Unit HM and Packing Group('d any)) 13.Waste Codes No. Type QuantityWI.NoI. Ix f NA —7-7, c- y r I )_ q UC7 SIC "' L t_ 2E 3. _ _... 4. E'�MPt NM AL l`FI .14.Special Handling Instructions and Additional Information E � M�xcO :r-UrvAA�i- f?.fZr t to ►J -- c, I Rao w ► U' fo 15. G@NERATOR'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 Iabeledlplacarded,and am 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 tens of the attached EPAAcknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)If I am a large quantity generator)or(b)(if I am a small quantity generator)is we. GeneratoeslOfferors Printed(Typed Name Signature ,/ 1 Month Day Year 16.International Shipments r— ❑Import to U.S. ❑Expod from U.S. Pon of entrylexi z Transporter signature(for exports only): Date leaving U.S.: w 17.TmnspoderAcknowledgment of Regfipl of Materials - A Transporter 1 PdnledRyp�Name / N Signature Month Day Year ZQ Transporter 2 PrintedRyped Name f Signature Month Day Year H 4. 18.Discrepancy 18a.Discrepancy indication Space ❑ Ouantity ❑T e yp El Residue ❑Partial Rejection ❑Full RejecBon Manifest Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA IO Number J ui. Facilites Phone: F1Be.Signature ofAltemate Facility(or Generator) Month Day Year Z e 0 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 2. 3. 4. Li20.Designated Facility Owner or Operator.Certification of receipt of hazandous materials covered by the manifest except as nyled N Item las Printedfryped Name Signature Month Day Year �,EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR