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07/01/2009 14:02 LANSAS PRODUCTS (FAX)2093398260 P.0071008 Please print or type.(Form designed for use an 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.Manliest Tracking Number WASTE MANIFEST ,;;.t'--' : <tR_-,?t_�.7a> n n,5 _ 9;i.59 7 JJ K 5.Generator's Name and Mailing Address Generator's Site Address(if different 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-may` ~ Br r&far /r J:r :rP.(! w=r"d,`.:f'S CA�';%�i��46,?,;,-7 9 8,Designated Facility Name and Site Address U.S.EPA ID Number Facility's Phone: ga. 9b.U.S.DOT Desaiption(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 WlNol. 40a Z 2. W tJ 3. ` I 4, 14.Special Handling Instructions and Additional Information J 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 EPAAcknowledgmenl 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. [Generatoq/Offerors Printed/Typed Name Si tune 11 Month Day Year ��7�.�•R1 iT:-7�.� i =1 i J 16.international Shipments ~ 1:1 Import to U.S. Ll Export from U.S. Port of entiutrylexit: Transporter signature(far exports only): Date leaving U.S.: LW 17.TransporterAcknowledgment of Receipt of Materials LW a Transporter i PrintedrTyped Name Signature r Month Day Yeah z Transporter 2 Printedrfyped Name Signature _ Month Day Year H d'":.• ..,J N�•. ti}r::-Yii�-� .i ,�- .F.� *-i.. r`I i'/'��+`� ::r^'^."'-^--•.....- rjr'':! C.e« sc 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 v` Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year a z y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) Q 1. 2. 3. 4. 1-t jL?I 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Pdntedrryped Name Signature ,5 Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR