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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 3.Emergency Response Phone 4.Manifest Tracking Number ]. WASTE MANIFEST Q ^r a 1 n 1 v 3 O FLE 5.Generator's Name and Mailing Address Generators Site Address('d different than mailing address) 9di t{.,+7 flouthYrwk, �f Ga-rs:c*nal 4,143 F$ Fzinazvm?Y &f- 9 telt-L tor) ^.A Generators Phone: ., 6.Tmnsporter CompanyName "' " " " U.S.EPA ID Number a,. .,.... -,..,... .r.. . .,..,. m 7.Trans one�2Com an Name �' ' -"- -• •,� P P Y �� -� U.S.EPA ID Nurribe """"„` " 8.Designated Facility Name and Site Address U.S.EPA ID Number DA Q0.- Y.tif4j' h7R.ifA tl,f dila'. Facacilityilii gal 9b.U.S.DOT Descrptor(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 WLN01. z 1 di, _ ..C?T3. 3? z,xrr;t+siyrll:au:�;xr. J::s�'i.Y:z..t9 itr�.C2@;t 1.tEk) am ;IS.A of w 3 ti;:t, r, r+,.n +�.::.::-:.�.r^F,., , . . }.•jib �1;n"r.; vcr;Ll.,�y3 4 �,,^:71" ��7 � 7#.3 t 4. 1♦4.Special Handling Instructions and Additional Information ! y .. �; tk7J;1.,47'13�_1GvR : idol 1•kS+e '�`s r5 yil t';I!J" .. ! �'`q �"t 15. GENERATOR'SIOFFEROR'SCERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classifed,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 M the terms of the attached EPAAcknowledgment of Consent I certify that the waste minimization statement identified in 40 CFR 261(if I am a large Quantity generator)or(b)(if I am a small quantity generator)is me, Ge�nexator rors PrIntedrryped Name bignaftne Month Day Year } Yb"zi Ty X M 16.International Shipments Z 1:1 Import to U.S. ❑Export from U.S. Port of entry/exit Transporter signature for exports onlyk Date leaving U.S.: w 17.Transporter Acknowledgment of Receipt of Materials Transporter l.PnntedRyped Name fSignature Month Day Year N QTransporter 2 PrintedlTyped Name Signature '« on ay ear CC r- 18.Discrepancy 18a.Discrepancy Indicetion Space ❑ Quantity ❑Type ❑Residue ❑Partal Rejection ❑Full Rejection Manifest Reference Number. F 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U Q LL Facility's Phone: W 18c.Signature ofAltemate Facility(or Generator) Month Day Year a z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for haurdous waste treatment,disposal,and recycling systems) 2. 3. 4. 1 20.Designated Facility Owneror Operator.Certification of receipt of hauMous materials covered by the manifest except as noted in Item 18a PrintedlTyped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY