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PJeAse,printnoriype.(Form designed for use on elite(12-pitch)typewriter.) Form Approved,OMB No.2050-0039 T UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST- . t IiI I I 'vI 34398 JJ K 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) Generators Phone: t 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 Site Address U.S.EPA ID Number / A, Faciliy'a Phone: gy 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 1D.Containers 11,Total 12,Unit 13.Waste Codes HM and Packing Group(t any)) No. Type Quantity W ivol. L j � z 2. RE EAxV'i=D1 W gg 3. f•1 Iy 0 2011 4. PE IT/9 RIACE I c r i 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 Iabeledlplacarded,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 ceNfy that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)it am a small quantity generator)is We. GeneratoesrO6erors Printedflyped Name Signature --------- Month Day Year —+ 16.International Shipments " i— L1Import to U.S. ❑Export from U.S. Pod of ani 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 aTransporter Pnntedlryped Name Signature Month Day Year od r 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Partial Re ❑Full Re El Rejection jection Manifest Reference Number. >- 18b.Alternate Facility(or Generator) U.S.EPA ID Number J V ra Facility's Phone: UJ 18c.Signature ofNtemate Facility(or Generator) Mont . Day Year 4 z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste Vestment disposal,aro"cycling systems) +. 2. 3. 4. 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1Be PrintedfTyped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY