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Please print or type.(Form designed for use on el to(12-pltcn)typewriter.) Form Approved.OMB No.2050-0039 �1,Generator IDN mber 2.Page 1 of 3.EmergencyResponse Phone 4.Manifest Tracking Number UNIFORM HAZARDOUS -- WASTE MANIFEST j; ,•: ,t ,.t ('' t F 4, f ;.f 0i '3 � r 77869 LE 5. enerator's Name and Matting Address Generator's Site Address(if different than mailing address)_ 4�„+t ✓,�I r#''��y'�,r' �v)tf � �' t'' f -: � F , '="f�� 4 L T91A.,/;t' 4,,`t,', Generator's Phond. 6.Transporter 1 Company Name U.S.EPA ID Number ) ? . a is r. y 1 g 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number 44 11 d M' Facility's Phone. G 9a 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. LLI UJ y ltd" Le-Y6 If 14.Special Handling Instructions and Additional Ink ation #J 15. GENERATOR'SIOFFEROR'S CERTIFICATIO : 1 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 a spects 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 consi gnment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement 1 Jentified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generator's/Offeror's Printed/Typed Name Signature_. Month Day Year —J 16.International Shipments ❑Importto U.S. ❑Export from U.S. Port of entry/exit: z Transporter signature for exports only): Date leaving U.S.: w17.Transporter Acknowledgment of Receipt of Materi Is I Transporter 1 Printed/Typed Name Signaturefyr Montay ear 0CL W ).., f t itYf`{r�NY.iL .: ," _- in SignatureMonth Day Year Z Transporter 2 Printed/Typed Name f-- 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quan ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U Q LL Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z CD 19.Hazardous Waste Report Management Methododes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 1. 2. r 4. 20.Designated Facility Owner or Operator:CertificarilDn of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY