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Please Hrini type.(Form designed for use on elite(12-pittpewriter.) - Farm Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1 Generator ID Number. 2.Page 117,mergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST f�,.')".:1 't^y"] ;den 7 j1 - r: ( '. OOnOl 8097 DAT 'S.Generatofs Name and Meiling Addmss Generatoes Site Address if different than mailing address) Generator's Phone 6.Transporter 1 Company Name r 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. Facilitys Phone:' t- t ga 9b,U,S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers it.Total 12.Unit HM and Packing Group(if any)) No Type: Quantity wt./VoIx l 13.Waste Codes Z i 4. ' 14.Special Handling Instructions and Addidonal Information ' �� iy�i+iC�7ch3'SJ R ? 15."GENERATOR'SIOFFEROR'S CERTIFICATION: 1 hereby dedare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labeledlpladarded,and are in all respects in propei condition for transport according to applicable international and national governmental regulations.If export shipment and I em the Primary Exporter,I carmly that the contents of this consignment condemn to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(If I am a large quantity gamester)or(b)(dl am a small quenfity generator)is true. GereemadesrOgemisPnntecirryped Name Signature Monnh Day Year r 16.Intemational Shipments z ❑Import m U.S. ❑Export from U.S. Port of entrylexit: Transporter signature(for exports only): Date leaving U.S.: w 17:TrensporferAcknowledgmesof Receipt of Materials - Transported PdmosirTyped Name Signature Month Day Year p a Transporter 2 PdntedRyped Name Signature Month Day Year K r t18.Discrepancy..: - 18a Discrepancy Indication Space ❑ Quantity ❑Type El Residue ❑Partial Rejection El Full Rejection Manifest Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA ID Number J u- Facility's Phone: - - w Ido.Signature of Alternate Facility(or Generator) Month DayYear l 19.Hazardous Waste Report Management Method Codes(I e.,codes for hazardous waste treatment,disposal,and recycling systems) 20.Designated Fadlity Owner or Operator..Certification of receipt of hazarcrous materials covered by the manifest exwgt as noted in Item 18a PdnM Typed Name Signature` Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. - GENERATOR'S INITIAL COPY