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r Please print or type.( orm designed for use on elite(12-pi ewdter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator 10 Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Trackln Number nn n n .� WASTE MANIFEST t 0 1 ; 1091 JJ K 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) Generator s Phone: 6.Transporter t Company Name U.S.EPA ID Number 7.Transporter 2 Cornpany Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number Facifi 's Phone: ga 9b.U.S.DOT Description(including Proper Shipping Name,Heard Class,ID Number, 10.Condi Ions 11.Total 12,Unit 13.Waste Codes HM and Packing Group(if any)) No Type Quantity Wt.NoL l 04 Ti kk.,I4.1Cs�rU A!F-d S,�� 1J Yrl• 11 W 2 C, 3. 4. 14.Special Handling Instructions and Additional Intonation ij� ;yr HC0 IF FfAf{ Flprh.'• C.id•G'.fT :,l,J 1,4^4' 2Hti!-424-CI 0 AND c:INCri OIRuINI ()k. 91°!F1:91.E: 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 labeledli lacarded,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 EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(x)(d I em a large quantity generator)or(b)(if I am a small quantity generator)is We. Generatoes/Offerors Pdntedlryped Name Signature Month Day Year 16.International Shipments F ❑Import to U.S. ❑Export from U.S. Part of entrylexit: Transporter signature(for exports only): Date leaving U.S.: w 17.Transporter AcknoWedgmenl of Receipt of Materials Transporter 1 Pdnted7Typed Name Signature Month Day Year O a n G Transporter 2 Printed/Typed Name Signature Month Day Year K H i 16.Discrepancy 18a.Discrepancy Indication Spars El Quantity ❑Type ❑Residue El j ❑ i Partial Re ectlon Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U LL Facility's Phone: W18c.Signature of Alternate Facility for Generator) Month Day Year Q Z LD 19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems) 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 16a Pnnhedu typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY