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�5 o� o.205 39 Plesne print or type.(Form designed for use on elite(12-pitch)typewriter.) UNIFORM HAZARDOUS 1.Generator ID Number 2.Pae 1 of 3.Emergency Response Phone 1 ManlNttTnckln NumWr WASTE MANIFEST 00484647 FLE 5.Generatoes Name and Mailing rf ,t CDS f�,�(�L A ,�/t, nerator's ite Address(i(d-Brent tltan mailing address) A�TO RWW SIDE 17-5 Irl. ktt+1 fS y NIP OF ALL HAZARDOUS V\ g 6 y MATERIALS BILLS AT L /'Q �1 � ° f �'�' SO TAB WILL STICK Of Gerrerabes Phone o 1— /— i WSA�1att�M.taoow+ Transporter6. 1 pang ame U.S.EPA ID Number 650 7.Transporter 2 Company U.S.EPA ID Ntrrnber C'9.-c1— 8. gnated Fadi Name erd SIM Address U.S.EPA ID Number .Wm�0.1 rr°a Faditys Phone: AD D 91 � 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)) INo. Type Quantity WLNoI. o '-UVja7$q, 04:1,44Z-+i(, i 1 Sgd.iiiL j,�I Daol Door 33 2�- z 2. W 3. 4. 1 pedal Handling Instructions and Additional Information 1 Gr c— 001 cN t->S3Zs - 8 4 15. GENERATOR'SIOFFER 'S CERTIFICATION: I hereby declare that the contents of this ccnsignmenl rib are fully and accurately desced 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 intema6enal and national governmental regulations.If export shipment and I am the Primary Exporter,I..fy that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent I cerMy 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 qu generator)is true. enerator erofs nnte ed Nama igna ne _ onDay Year C X 9 1 24 J 16.lnte do hipmen I— ❑Impo to U.S ❑Export from U.S. ort of en rylexil _ Z Transporter signature for exports only): Date leaving U.S.: ly 17.TransporterAcknowledgmenl of Receipt of Materials LLJW TransporterAl t yped Name g a re on a Year �i 'e,'✓I q I QTransporter� 2 Pdntedi typed Name �C ` ` tore f Monthay Year of 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Fult Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U 6 LL Fadl' s Phone: w 18c.Signature of Altemate Faal'dy(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) O 1 2. 3. 4. 20.Designated Facility owner or Operator.Certification o receipt of hazardous materials covered by the manifest excsp noted in Item 18a � Prin Name y � Signature a Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACII-In46DESTINATION STATE(IF REQUIRED)