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Please print or type.(Form designed for use on elite(12-pitch, _. :writer.) 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 a j;t`?t ir�l:�;s? "ti:!1 i. Z-.13u 7.:1T,•7,T 7111 t-- ' .J 11 F L E 5.Generator's Name and M ail ing Addre ss Generator's Site Address(if different than mailing address) F.ikai-.:r."' t`b-3. Xr1.m.f!5i 1.1 77.+ P1t'tdkh riu.07,64 fit 4e. Generator's Phone: •11 .1617:i t 6.Transporter 1 Company Name U.S.EPA ID Number i{)u1:.41 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number fs:, t.r'r..)f i5�frq )ti... �'l:.{'�1, -iii'. �'f '(3 itL'R:li wits, 6.i:( !t, A-L 1; 1: :-11'r f)i+tilt.: Facility's Phone: i3 f.)Vf..%?,3 '�t:•i i`a:> 533i� .€fi3(3¢) ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Gro.ip(if any)) No. Type Quantity Wtivol. 13.Waste Codes 1.�.3i'A/.i iC�=.r.. Td h,•�tr.tr�in.dc. Lrtiit:':�_•',. �>.�T.�rW.ld. ��S'i:%.Y!.'•'. '�t�-d. z 2. w cq 3. 4. / 14.Special Handling Instructions and Additional Information / 1 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 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(a)(if I am a large quantity generator)or(b)(f I am a small quantity generator)is true. eneratorslOfferors Printedrfype ameSignare on ay ear lie -J 16.International Shipments ❑Import to U.S. ❑Export from U.S. Port of entry/exit -- Transporter signature for exports only): Date leaving U.S.: 17.Transporter Acknowledgment of Receipt of Materials Ll Transporter 1 Printedrryped NameSignature) ft Month Day Year CL Z¢ Transporter 2 Printecirryped Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Typej ❑Residue Partial Rejection Full Rejection Manifest Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U Q Facilit s Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year LD4 Z Y,; 19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems) 0 1. ,- 3. 4. 20.Designated Facility Owner or Operator.Certficatlon of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printedffyped Name Signature Month Day Year .PA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY