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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 1.Generator ID Number 2.Pae 1 of 3.Emergency Response Phone 4,Ma 'fes Tr c ' umber UNIFORM HAZARDOUS 9 9 p 6 �� FLE WASTE MANIFEST CAI�I�(�1c54V7 i 1 �'� -T?'�S 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) u�lt�-G�ti Neurxs}�i�ie, Mtic. 11'5�S. OL�*dr��AAw Generators Phone: IRM 6.Transporter 1 Company Name U.S.EPA ID Number A& rwed Ghetrecall Trr,MIX4 tic. (3V) C,ry.R001007105AO 7.Transporter 2 Company Name U.S.EPA ID Number ED 8.Designated Facility Name and Site Address t U.S.EPA ID Number JSCdJ( w1iI� 41C. � NV«M1d k rtJ it�7r a H1,v t3�,1 1 titA� � f3��tty "se ttY, IAV Facility's Phone: "52." oa 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes H61 and Packing Group(if any)) No. Type Quantity WtNol. 1-ON RCRA HAZARDOUS WASTE.UQUIf)(WATER) Q ,.r LU ?40N RCRA HAZARDOUS WASTF, (PAINT `31,Ut)GFJ IL " Jftj 14.Special Handling Instructions and Additional Information )ERC, ; 0M31fi70-2`Luu 15. GEN ERATOR'SIOFFEROR'S CERTIFICATION•. I hereby declare that the contents of this consignment are fully and accurately descr bed above by t and are classified,packaged, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national government—".0... nt and I am the Primary Exporter,I cerfify 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. GeneratorslOfferors Printed/Typed Name ignature Month 0"' Year 1 j 16.International Shipments f f— ❑Import to U.S. ❑Export from U.S. Port of entrylexit: - z Transporter signature ffor exports only): Date leavin'U.S.: w 17.Transporter Acknowledgment of Receipt of Materials Tra r 1 rin d/T ed Name ♦ ignature�l Month a Year 41A (V/1 . z Transporter 2 Printed/Typed Name Signature Month Uay Year Q rr 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑ResidueEl j j Partial Rejection Full Rejection Manifest Reference Number: I8b.Aiternate Facility(or Generator) U.S.EPA ID Number J_ U Q Facility's Phone: 18c.Signature of Alternate Facility(or Generator) !+!on;h Day Year LUQ z 0 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) r2. 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 COPY