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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS—1 1.GeneratorlD Number 2.Page 1 of 1 3.Emergency Response Phone 14.Manifest Tracking Number IWASTE MANIFEST ;',! 007302564 JJ K r ; L 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) ' � s Generators Phone: 6.Transporter 1 Company Name_ f U.S.EPA ID Number a 7.Transporter 2 Company Name U.S.EPA ID Number ' 8 Designated Facility Name and$ite Address U.S.EPA ID Number Facility's Phone ga 9b.U.S.DOT Description(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 Wt.Nol. 1 Z 2. W 3, 4. 14.Special Handling Instructions and Additional Information ' �� 1 ��4.. i � LAG j�tt ��-; � ) r.�;� r. •�� .. � rCr r ta. 1 v/�I r, ` c_1( : �1lr (.'r7. _, , r._` ./� 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are,fully and accuiately descr bed above b'the proper shipping namA'ard 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 cenity that the contents of this consignment conform to the terms of the attached EPAAdmow(e hvrTt 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. Generalors/Offeroes Printed./Typed Name Signature Month Day Year r x' J 16,International Shipments ' F ❑Import to U.S. ❑Export from U.S. Part of entry/exit Transporter signature(for exports only): Date leaving U.S.: W 17 Transporter Acknowledgment of Receipt of Materials Transporter 1 Pnnted/Typed Name Signature Month Day Year z Transporter 2 Printed/Typed Name Signature Month Day Year Q t- 1 B.Discrepancy 18a,Discrepancy Indication Space ❑ Quantity El Type El Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U LL Facilitys Phone. Lo 18c.Signature of Alternate Facility(or Generator) Month Day Year a Z y19.Hazardous Waste Repod'Ma_nagemenl Method Codes(i.e.,codes for hazardous waste treatment.disposal,and recycling systems) t. 2. 20,Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted In Item 18a Pdnledrryped Name r Signature t" ^.._ Month Day Year EPA Form 8700.22(Rev.3-05) Previous editions are obsolete. TRANSPORTER'S COPY