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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 f, . J, f ?I, '. °) JJ K WASTE MANIFEST y"i�.t .rl St; 3 U U. ..1 , r �. 5.Generator's Name and Mailing Address f:i•'1l 3hpil Generator's Site Address(if different than mailing address) 2494 V Fremont :fit. ftocktctn, r A 05205 Generator's Phone: � `� '� 6.Transporter 1 Company Name U.S.EPA ID Number 1'aiitot"nidi Sory ire c,%I--� 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number i✓:3t)el�, t,1(Vit0t11 (-,UtA R`fif.'• iig9 {r ti;• iR?i 1515 3. P ivtrr• 1'd sar"rt lahEn, 0A 04601 Facility's Phone: ga 9b.U.S.DOT Description(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 Wt.Nol. 1. ry •ti z 2. ,W V 3. 4. 14.Special Handling Instructions and Additional Information 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 labeled/placarded,and are in all respects in proper condition for transport according to applicable intemational 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(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generator'slOfferor's Printed/Typed Name Signature Month Day Year J 16.International Shipments F ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Z Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials F- Transporter 1 Printed/Typed Name Signature Month Day Year O r.., QTransporter 2 Printed/Typed Name Signature Month Day Year F 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J_ U LL Facility's Phone: w 18c.Signature of Altemate Facility(or Generator) Month Day Year H Q z O 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 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 18a Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL Cr