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04/09/2012 04:03 #6212 P.004/016 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 0083604 it 2 JJ K 5.Generator's Name and Mailing Address Generators SiteAddiess(if 0brent than mailing address) Generator's 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 U.S.EPA ID Number Facilitys Phone: ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) No. Type Quantity W't.Nol. 13.Waste Codes 1. t.. z - W 3. � r i 4. r r 14.Special Handling Instructions and Additional information _ .. "'•j•i. -.'f , .,;: .� •'7:... - Y:.lam, r...i'• ... �I, .: ... - .. 15. GENERA TOR'S10FFEROR'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 labelediplacarded,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 EPAAcknoWedgment 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)lift am a small quantity generator)is true. Generators/Offerors Printedlfyped Name Signature Month Day Year F 16.Int'emational Shipments t- ❑Irapa t to U.S. ❑Exportfrom U.S. Port of entrylexit: Z Transporter signature(for exports only): Date leaving U.S.:. W 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Pr ntfld/fyped Name y� Signature t ? Month Day Year O Q Trans�prfer 2 Pnhted(fype f Name Signature, ^'�-K Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type Residue ElPartial Rejection ❑Full Rejection ❑ Manifest Reference Number 18b.Altemate Facility(or Generator) U.S.EPA ID Number _i Q L Facilitys Phone: w 18c.Signature of Xtemate Facility(or Generator) Month Day Year Q Z 19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatrnent,disposal,and recycling systems) LLJ� 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/I yped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY