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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Appromed.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2 Page 1 of 1 3.Emergency Response Piwne T.ManHest�T Harahan FLE a WASTE MANIFEST _ —. 5.Generators Name am Mailing Address _ Generators See Address in ddierent mai mailing address) GNurabrs Phone: 6.Transporter t Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number _ l 8.De$ignated sonify Name and SiteAddress .. U.S.EPA IO Number Facility's Phone: 9, 9b.U.S.DOT Desorption(Indudng Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11 Total 12 Unit HM and Packing Group(d any)) No. Type Quantity NANol. 13.WtlY CaM 2. O 3. r 4. NOV 0 3.2 14.1pecialHandlingbalructionsandAdditionalatfonnaticn ENVIRONMENTALI HEALTH I DEPARTMENT I 15. GENERATOR'SIDFFFRDR'S CERTIFICATION: Ihereby declare Mat the contents of this consignment are fatty and accurately described above by the proper shipping name,and am dassfied,packaged, marked and Iabele#lacarded,and are in all respects in props corditgn for transport according to applicable international and national governmental regulations.If export shipment and I em the Prirrsry Eporler,I cartty that the contents of this consignment conform to the terms of the seamed EPA Atbwwledgment of Consent. I certfy that the waste minimization statement identified in 40 CFR 262.27(a)(d I am a large quantity generator)or(b)(if I am a small quantity generator)is We. eneratoesi rots PnntecVTypW Name oignature Pon . ay ear —ni6.nrematicnal 6hilwanis Evora from US. Pat of en Ir— Transporter ❑Import to US, ❑ try/wan: Trare rater signature for exports only): Date leaving LLS.: w 17.TraraponerAclmmmdgment W Receipt of Materials Transporter 1 Pureed Typed Name Signature, Month Day Year do i I I Q Transporter Prn*Vryped Name Signa ire Mor th Day Year c I I I F 18.Discrepancy Ise.Discrepancy Indeagon Space ❑ Duantdy ❑Type ❑Residue ❑Partial Rejection ❑Full Rgeceom Manifest Reference Number: 16b.Alternate Facility(or Generator) U.S.EPA IO Numoer J U a LL Faa1i s Ptane: W 1Be.Signature of Alternate Faatty(or Generator) Month Day Yes z S2 19.Hazardous Waste Report Management Method Codes(IA.,does for hazardous weans beamrent dsposd,and recycling systems) 0 7. 2 3. 4. 20.Designated Facllity Omer or Operator:Certification of receipt of hazardous materials covered by the maddest except as noted in Item las Frmumi,yped Name Signature Morath Day Yes EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. _ ,�