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'j- P!�V�'se print or type.(Form designed for use on elite(12-pitch)typewdter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST 01 OP '� r17-0 JJK 5.Generator's Name and Mailing Address f t Generator's Site Address(if different than mailing address) -71 --4 % Generators Phone: <-q F V Ginp 6.Transporter 1 Company Name U.S.EPA ID Number 4F'�.ITAL t7 7.Transporter 2 Company Name U.S.EPA IDNurnbb".ftN# 16Jj% 8.Designated Facility Name and Site Address U.S.EPA ID Number 1,4 �jA,t n-;n r. Facility's Phone: t ft 9a. 9b.U.S,DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 1111.Total 12.Unit HIM and Parking Group(if any)) No. Type Quantity WMol, 13.Waste Codes 0 3. 4. 14.Special Handling Instructions and Additional Information so. 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and arcuratety 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 Prime t Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. 1 dar*that the waste minimization statement identified in 40 CFR 262,27(a)(if I am a large quantity generator)of(b)(if I am a small quantity generator)is true 9ene'ratDeEWOfferoes'Pdntedrryped Name Signature Month Day Year -1 16.1ntemational ShipmentsIp 0 Import to U.S. E]Exporl from U.S, Pori of entry/exft: Transporter signature(for exports only): Date leaving U.S.: 17.Transporter Acknowledgment of Receipt of Materials, Transporter I Printecirryped Name Signature Month Day Year 0 Z Transporter 2 Printecirryped Name Signature Month Day Year Ce 18.Discrepancy 18a,Discrepancy Indication Space El Quainfltyl El Type ❑Residue ❑Partial Rejection El Full Rejection Manifest Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA ID Number Facility's Phone: LU 18c.Signature of Alemate Facility(or Generator) Month Day Year Z 0 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 1.LLI — 1 2.; 20. led Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 188 Printedfryped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are,obsolete. GENERATOR'S INITIAL COPY