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Please print or type.(Form designed for use on elite(12-pitch writer.) • Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Mantleet Trackin Number WASTE MANIFEST "- O U 14 � / 4 2 I J J K 5.Generators Name and Mailing Address Generators Site Address in different than mailing address) IRi c:i'ENIIGAI. n 1-AX1 S roll L URD:i9 C.P T'DN,Ca. t2p; Generators Phone. 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 ;iiEM1k:/'L'•4'.,�rTp 1d.>)darA`J kiNT, TIC' U.S.FPA ID Number x:31 i.";+Y-YLIPIp ROAD •�rrLersAw t:trr, ,>a ,.;z� Facilirys Phone: i' "''• 4 9a. 9b.U.S.DOT Description(Including Proper Shipping Name,Hazard Class,10 Number, 10.Containers 11.Total 12.Unit HM and Packing Group(it any)) No. Type Quantity NA.Noi. 13 Waste Codes 1. i'31 r t - d�+1'1. it rn3 ;,..:rl - r.4.tq i :1 :.3 i n F O W 3. 4. 14.Special Handling Instructions and Additional Information rr.,;•.F7t.,'.F.:: .�iN)r 9.0 z;F 1F•-11 dF0 p;O l.i;l3 -PPFO ,..'7 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 Iabeledrplacarded,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 ceNfy that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I ceNly that the waste minimization statement Identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(ffI am a small quantity generator)is We. Generatoes/Offemrs PrintedRyped Name Signature Month Day Year J 16.International Shipments. i Elimport 1,U.S. Dwarf from U.S. Pon of entryleAt Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printedrryped Name Signature Month Day Year O - ansporter2 PrtntetllTyped Name Signature Month Day Year } 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.B.EPA ID Number J U ra+. Facttiys Phone: u, 18c.Signature of Alternate Facility(or Generator) Month Day Year Z y19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systema) 1. 2. 3. 4. 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted In Item tae PrinteNTyped Name Signature Monts Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY