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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 Generators 10 Number 2.Page i of 3.Gly Em 5ncy Response Phone 4.Manifest Tracking Number WASTE MANIFEST r lZ-rte".✓'-1_I f+. .,,' ;t„�y r' f 4.' JJ K Generator's Name and Mailing Address - Generators Site Address(if different than mailing address) — Generator's Phone: _` !i 7 /L/ C__l i 6.Transporter 1 Compan�Name U S.EPA ID Number 7 c::.1✓� � i t" s,l l J c";i, 7.Transporter 2 Company Name U.S.EPA ID Number 8 Designated Facility Name and Site Address { _ p U.S.EPA ID Number [. tlLUt/ C'i �� / jl(`ia�i J. i r t" ( _fi7% ✓d�/f °v _ //� Facility's Phone: _ 3VV s, ✓�'- ` ga 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 WtNol. r% G G t2 U�,W)2 3. MAI 0 2 017 4. "EALTF- ES .Special Handling Instructions and Additional Information --`r- Jf ii1J ilk' i vF ILE J77C ) �f 1 - rr fl r'f • 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I herebydeclare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labeled/placarded,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. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b) small quantity generator)is We. GeneratorslOfferor's Printeyd�RLyped N�amre- Signatures- Month Day Year .r 16 International Shipments - t- El Import to U.S. El from U.S. Pod of entrylexit Transporter signature(for exports only): Date leaving U.S.: w 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/ryped Name Signature Month Day Year O 01- W Z Transporter 2 Printe irryped Name Signature Month Day Year H 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J V Q LL Facility's Phone: - w 18c.Signature ofAllemate Facility(or Generator) Month Day Year ti a z _ 720 azardous Waste Report Management Method Codes(i.e.,codes.for hazardous waste treatment,disposal,and recycling systems) -� � 2. 3. 4. esignated Facility Owner or Operator.Cedificabon of receipt of hazardous materials covered by the manifest except as noted in Item 18a edlTyped Name Signature Month Day Year ji orm 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR